There is no cheat sheet for 2014.

Now is the time of year when we all have 12 things to do in the next 30 minutes, plus we are budgeting and we need to write our strategic approach for 2014. We have to learn how to prioritize and focus on what is truly important to our success. Unfortunately, there is no cheat sheet, no best practices for all things healthcare, and we cannot succeed if we have too many strategies. Let's compare five areas:

  1. Administrative excellence and compliance
  2. Clinical innovations around case, disease, and utilization management
  3. Provider Engagement
  4. Risk Adjustment
  5. High-risk member management

Recently, Gorman Health Group asked the attendees of Medicaid Health Plan Association, "What are the most important strategies in 2014?" The answers and ranking are below:

  1. High-risk member management
  2. Provider engagement and innovative reimbursement models
  3. Risk Adjustment

I imagine that this may be that cheat sheet for all of us.

Although Michael Porter shares, "strategy is about making choices, trade-offs; it's about deliberately choosing to be different." There are some strategies that every business has to do well to survive, and we all need to be ready to succeed at those mentioned above in 2014.

 

Resources:

Decision-makers from Health Plans and Provider Organizations are invited to join GHG for a free webinar on November 19th: "The future of the Government sponsored health care."  Register for this free event now >>

Medicaid health plans must be able to navigate through State and Federal regulations and work well with State agencies.
GHG solutions-based consulting drives results to your Medicaid health plan, visit our website to learn how >>

 

 


The survey says...

In May, GHG conducted several marketplace surveys. The initial survey highlighted our clients' top priorities. Here is what the ranking showed as our clients' focal points:

  1. STARS
  2. Clinical & Financial Alignment
  3. Risk Adjustment
  4. MLR monitoring

We understand that in order to emerge as leaders or at least survivors of the rate reduction and complex regulatory world we live in, health plans, health systems, ACOs, and capitated medical groups have to identify business levers that impact the greatest improvement to the bottom line. This is exactly why we created the Alignment Innovation Suite - we take your data and create a driver and alert system for an interdisciplinary team to review and discuss. The Alignment reports clearly indicate where the problems are and where we can jointly create the road map to fix them.

The new Alignment engine couples medical cost and utilization while at the same time overlays benefit and network design. The reports display the areas in the greatest need of collaboration and redesign, i.e. where to spend your time and resources to get the best bang for your buck.

In recent GHG case studies, the Alignment engine, assessment and reports clearly depict the need to 1) redesign provider payment models, 2) completely restructure health services or medical management functions and criteria to impact population health management & patient engagement , 3) operational improvements; simple changes with huge financial impacts and 4) benefit remodeling to improve patient navigation of your healthcare ecosystem.
Resources

GHG's Alignment Solution Suite assessment is backed by industry leading health care expertise and is managed by a team of veteran consultants who will help lead your organization to better financial alignment, product design and health care efficiency. Visit our website to find out more.

Join us on August 8 to get practical advice on the best ways of getting into the MA market from GHG Chief Development Officer, Aaron Eaton, Senior Vice President of Finance, William A. MacBain, and Senior Director of Compliance Solutions, Regan Pennypacker.


Not a Narrow Network - A Smart Network

What we learned in Medicare + Choice is still true today, we don't need narrow provider networks; we need aligned provider networks, aka Smart Networks. We have also learned that narrow networks often cause ill-will with your health systems and uncontrolled leakage. A Smart Network builds a mini-healthcare community similar to an ACO in your healthcare delivery ecosystem. A Smart Network can focus on a health system and it's provider feeder system or it can better engage your Primary Care Physicians (PCP) and "rendering" PCP. Smart Networks typically are invisible to members; however some payers may differentiate copay to encourage Smart Network utilization.

What is a Smart Network?
It is provider community aware, educated, and contractually aligned with the health plan or payers objectives around member health status, medical cost, care delivery, and health outcomes.

What is needed to develop a successful Smart Network?

  1. DataWarehouse: Success is built on capturing and compiling claims, lab, pharmacy, provider, eligibility, benefit, risk adjustment, and premium files on a very timely basis. This datamart needs to issue reports clearly displaying the successful areas of performance excellence and areas for alert and in need redesign. This is the health plans early warning system and strategy monitoring instrument.
  2. Multidisciplinary teams: The payer needs to know and monitor the data, drivers, goals and objectives; plus the provider partner need a team to absorb, implement, and impact the drivers and objectives.
  3. Slow and Steady Deployment: Not everyone can be globally capitated; make certain your team have expertise in gain-sharing for cost reduction programs, bundling payment programs, episode of care models, and mixed payment innovation models so this new structure is a win-win. The reimbursement methodologies may need to include assurance around participation in data capture exercises, code specificity, closing gaps in care, and other outcome, STARS, or risk adjustment initiatives the payer may deploy. Design your methodology; forecast its impact, and internal redesign the workflows touched on both sides — payer and provider.
  4. Network Management Touch: Make certain you are paying claims timely and accurately today. Health system or providers don't like to partner with those with "high administrative burden." Thus, consider having the following Network Management structure: 1) telephonic claims & process efficiency liaisons 2) contract negotiations and 3) educator, communication, and report review liaisons.
  5. Joint clear objectives for the SmartNetwork: whether it is a health system, cardiology practice, oncology association, a group of dialysis centers, nephrologist, endocrinologists or an ancillary provider makes certain the teams, objectives, and monitoring reports clearly understand, agree on and represent the short term and long terms goals.
  6. Early & Continued Dialogue: The initial dialogue will highlight if a provider may be a good SmartNetwork partner and the commitment of monthly or quarterly joint operation committee meetings will cement it. The original initiative may have a flaw in the development or implementation so this joint committee will need to review the impact and augment as needed.

Two closing thoughts:

  1. Remember bonus payments to providers are considered part of the medical cost in your MLR calculation.
  2. These Smart Network initiatives often need external support with design expertise, implementation experience, credible reporting design & product, and often a bit of mediation.

GHG is always eager to support the exploration and development of SmartNetworks. We have team members who have worked within PHOs, ACOs, IPAs, large health plans, and specialty medical providers; we are here to help if you need it.

 

Resources

Gorman Health Group's Senior Vice President of Public Policy,Jean LeMasurier discusses the recent CMS Medical Loss Ratio (MLR) regulation and its provisions.

GHG is helping many experienced plans by developing smart networks: accountable care, shadow capitation, and payment bundling within their current service areas and networks. Visit our website to see how we can help you too.


Solving your claims-based HCC conundrum

Everybody knows that 37% of claims-based HCCs fail in a RADV audit, but no one ever talks about how to fix the problem.

How to fix the high failure rate of claims based HCCs?

1. Filter your claims and tier into confidence levels (high, moderate and low). (We call our filtration, tiering, and resolution tracking solution CareCurrent.) We recommend you filter on frequency, site of service, provider of service, clinical significance, plus CMS compliance and clinical condition alignment.
2. Audit your medical groups with both the highest member density plus your providers consistently in your low confidence coding tier.
3. Note the diagnoses or most common conditions inaccurately recorded.
4. Meet with physicians and staff to create an evaluation to billing process improvement workflow for your top three most common inaccurate codes. Repeat this education and communication with other medical groups.
5. Re-stratify your claims and note improvements using CareCurrent if you have no internal system.
6. Audit the new dates of service stratified and glean if the education and new workflow aided in more specificity or accuracy in coding.
7. Create clinical and coding initiatives as appropriate to compliment your coding areas of improvement.

If you note that previous codes were inaccurately billed in claims and submitted to CMS, delete the codes prior to final sweeps to ensure appropriate payment and audit success.


Integration around chronic conditions, such as chronic kidney disease

Many of our clients have requested customized mapping and integration which electronically links the findings from the Advanced Evaluation into their medical management system.  Health plans and medical groups both appreciate the in-depth reporting, plus electronic connection that triggers or flags particular members for placement into unique case management programs, whether it is a COPD, CHF, frail and fall reduction, or chronic kidney disease referral.

This is an easy workflow to ensure the data is transformed from a picture in time to an integrated care support tool.
One of the diagnoses we focus on a great deal is Chronic Kidney Disease.  We have built a specific module around the clinical guideline statement from the National Kidney Foundation regarding Chronic Kidney Disease and have engaged experts to ensure our clinical analytics, detection, and evidence based findings are easily understood by the members, interact with the health plan's platform, and are simply formatted for community physician plan of treatment development. 

Dr. Dambro, CMO and Dr. McCallum, CEO of CenseoHealth will be sharing more information about our chronic disease modules and clinical outcomes in future conferences and blogs. Stay tuned.


Physician Engagement... What can you really do?

Health plans have tried a hundred ways to engage providers — incentive stipends, P4P, P4Q, capitation, clinical initiatives, episode of care payment, onsite coders, in office case management liaisons. But what works?  Open communication, reasonable expectations, and simplicity.

Before CenseoHealth launches a patient evaluation program we meet with the community physicians to discuss:
1. Program Overview
2. Program Goals & Objectives
3. Community Customization & Clinical Opportunities
     a. What are you doing well?
     b. What do you need help with?

Often Censeo receives questions similar to those that follow:
• What are you doing with my patients?
• What can you really diagnose in the home?
• What do I receive from the Censeo clinical team?
• What if I want to participate?

Again, CenseoHealth shares the following:
• Program from launch to closure
• JAMA articles and clinical research & guidelines utilized in the Censeo programs
• Proprietary iPad tool and outputs for the evaluation
• Open Invitation to participate whether conducted in the office or home

As your internal metrics may highlight, between 8% and 30% of the membership may go to the physician's office for an evaluation, if encouraged. If the network physician has the same tool and the same time allotted for the visit, the outcome can be just as successful. However, if the physician's time is limited, the data collected is also limited. The averages results for an in-office evaluation completed in 25 minutes are approximately 1/3 of the information collected during an in-home evaluation; therefore the premium impact in the office is about 1/3 of the in-home impact.
How does CenseoHealth counter act the lower in-office results?

• invite the community physician to utilize the proprietary tool via iPad or paper
• educate network physicians on the HEDIS, STARs, HCCs, compliance, and accurate coding
• schedule in-office visits for the medical group to ensure the needed time is allocated for the experience
• completed quality assurance, coding, and analytics for the medical groups
• meet with both the health plan and medical to review reports and programs successes

We make your network part of the team and solution. Physicians are great team members when they are invited, respected, and given the premier instrument for success.


Garbage In. Clarity Out

So you may have bad, ugly, horrible, scary data and internally you don't have a means to lump it all together to give you a clear picture of what happened in 2010, 2011, and the challenges you are facing in 2012 with your members, your network physicians or your risk adjustment program.

You have twelve or more different revenue and quality initiatives and twenty different vendors supporting you. How can you combine these or give one clear picture? You need to build an internal repository for charts, claims, and risk adjustment data, which marries your claims and clinical data for each member and each network physicians' profile. Here is how we provide clarity for our clients:

1. Actionable Member Profiles: by combining Censeo Health's Advanced Evaluation, CareCurrent, and CareConnect analytics and reports, we can show you and your physicians the whole picture of the member's history, current conditions, plus what case management programs they have triggered, and the documentation strength of the codes recorded for the member. The complete and actionable member profile is a "must have" output from your risk adjustment and quality systems.

2. Comprehensive & Insightful Physician Profiles: through our service offerings, Censeo highlights coding strengths and weakness, compliance areas of improvement, support documents and elements for a patient's plan of treatment from labs to pharmacy to chronic conditions and possible gaps in care, clinical program and pathways needed, and a monitoring system for the resolution of condition or gaps in care by the community physicians.  You need to support the network physician's plan of treatment by providing actionable and insightful tools for the physician as the patient navigates the care pathway.

These are not static report cards with a problem list but rather a dynamic instrument supporting your clinical success and engagement programs.  If your system has these elements, fabulous - you are on top of your game. If you are developing these,  wonderful - you are on the right track. If you cannot develop these internally, we can create this complete clarity for you in ten (10) business days through our mapping system and integration engine.


The Goat Rodeo

You hear a lot of interesting comments when you are meeting with health plans and large medical groups. One of my favorite phrases is "last year was a goat rodeo." The visual makes me laugh every time — goats, kids, and general goat chaos. However, in risk adjustment, you cannot afford an internal or vendor "goat rodeo."

If last year you had a risk adjustment goat rodeo, start taking notes and you may want to ask for some strategic planning assistance.

Here are the quick start metrics you should collect, map out, and monitor:

• 2011 Chart Review Volume, ROI, and projected timing of premium impact
• 2012 Hospital Data Feed Schedule from their HIMS database
• 2011 Member assessment volume, ROI and projected timing of premium impact
         o Percent and impact by PCP
         o Percent and impact in the SNF setting
         o Percent  and impact in the in-home
• 2011 Member data link to member services, case management, and PCP
• 2012 Chart review and member evaluation findings strategies linking to care
• 2012 Gaps in care closure program (outreach to documentation verification)
• 2011 HEDIS deficiencies and resolution success
• 2012 HEDIS program roadmap
• 2011 STARs goals and impact
• 2012 STARs roadmap
• 2011 & 2012 Claims based HCC analysis and documentation closure initiative

If you have a roadmap with timelines and an internal project leader for these aforementioned tasks you may still headed for a goat rodeo. The final pieces to ensure success are internal controls, plus a strong, efficient, and effective partner.


Your Risk Adjustment Road Map

Where are you going? And how quickly are you getting there? 
The risk adjustment model is evolving rapidly because of RADV, EDPS, and your health plan competitors.

Health plans and medical groups are moving from a chart review model to the premier member knowledge & engagement model.  Your transformation should look like this if you have PFFS, PPO, or HMO products:

• Early Model: 1.7 charts reviewed per member with no member evaluations
• Next Model: 0.65 charts reviewed per member with 5-15% member evaluations targeting
• Goal Model: 0.30 charts reviewed per member with 60-85% member evaluations targeting
• SNP Goal Model: 0.50 charts reviewed per member with 100% member evaluation targeting (we will blog more about SNPs soon, due to their unique nature) 

This not only offers you more timely and accurate revenue but, more importantly, member information for a comprehensive plan of treatment which should reduce gaps in care and highlight care management needs for  the patient population. 

If you have questions or need to remodel your strategic plan or budget, we have a client roadmap module to transition your risk adjustment program without impacting accurate revenue or blowing your budget.


A Risk Adjustment Road Map

Where are you going? And how quickly are you getting there? 
The risk adjustment model is evolving rapidly because of RADV, EDPS, and your health plan competitors.  Health plans and medical groups are moving from a chart review model to the premier member knowledge & engagement model.  Your transformation should look like this if you have PFFS, PPO, or HMO products:

• Early Model: 1.7 charts reviewed per member with no member evaluations
• Next Model: 0.65 charts reviewed per member with 5-15% member evaluations targeting
• Goal Model: 0.30 charts reviewed per member with 60-85% member evaluations targeting
• SNP Goal Model: 0.50 charts reviewed per member with 100% member evaluation targeting (we will blog more about SNPs soon, due to their unique nature) 

This not only offers you accurate, more timely revenue but, more importantly, member information for a comprehensive plan of treatment which should reduce gaps in care and highlight care management needs for  the patient population. 
If you have questions or need to remodel your strategic plan or budget, we have a client roadmap module to transition your risk adjustment program without impacting accurate revenue or blowing your budget.