Star Ratings: Medication Management Is Not Just for D Ratings Anymore!
As a pharmacist and Star Ratings Senior Consultant for Gorman Health Group, whenever I am asked to provide insight on how to achieve or maintain Star Ratings success, the conversation has been limited to the "D" part of the metrics, and the folks involved with Medicare Advantage (MA) and Healthcare Effectiveness Data and Information Set (HEDIS®) kind of glaze over and mumble something like, "That's for the Pharmacy folks to deal with." That attitude has always been somewhat befuddling to me considering the historical and ever-increasing impact of appropriate clinical management of medications on many HEDIS® measures and the quality conversation in general. Equally confusing to me has been the willingness of many pharmacists to relinquish the ownership of the medication-related HEDIS® measures to Quality, Case Management, or other teams.
The team approach, with the patient at the center of the team, is vital to delivering high-quality care. At many health plans, the Star Ratings teams historically have been "siloed" into medical Care/Case Management on one team and Pharmacy on the other. While we at the health plans were all focused on Star Ratings for the past several years, something happened outside of MA that will have a huge impact on the whole spectrum of healthcare. That event was MACRA — the Medicare Access and CHIP Reauthorization Act of 2015 — the latest and most sweeping healthcare reform law from Congress. MACRA will fundamentally change how healthcare providers are paid. Under value-based payment, the foundation of the reward system will be quality. Out of this change will come huge shifts in alignments and the creation of new partnerships requiring "outside-the-box" thinking. At the center of many of these new partnerships will be the critical role of the pharmacist and medication management.
Health plan Star Ratings teams would do well to pay attention to these profound trends outside of MA and understand the huge impact on how care will be delivered in order to respond to these changing incentives. Wasn't the Star Ratings system one of the early forms of value-based payment? Certainly if metric success is not achieved, there is a huge financial impact that will be incurred. A cornerstone of value-based payment is preventing hospital admissions impacted by many aspects of care but notably including a huge focus on medication reconciliation, medication management, and medication adherence. Sound familiar?
So how do we take these shifting sands and turn them into something tangible? The first step is collaboration. Star Ratings teams need to prepare themselves for a global value-based system by no longer segregating their teams into "C" and "D." And even if teams meet in an integrated way, the pharmacy members need to take the lead on metrics that extend beyond adherence and Medication Therapy Management (MTM) Comprehensive Medication Review (CMR) rates. Pharmacists should be taking the lead on new metric challenges like medication reconciliation even though they are a HEDIS® measure. A strong medication reconciliation program not only impacts the "checking of the box" that it was done but, if done right, has been shown to actually have an impact on reducing hospital readmissions (another Star Ratings measure). So this is good for Star Ratings, good for the plan, and, most importantly, good for the patient.
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Every organization in the healthcare industry will be impacted by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Gorman Health Group's Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, Dan Weinrieb, provided insight into the various options Providers will have if the legislation moves forward in a previous blog post on the subject >>
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
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How to Efficiently Conduct an Audit
Audits from regulatory bodies swarm around an organization like bees. And like a bee, upon first sight we do not think of the value they bring, but instead we first think of the sting that is to come.
A key aspect of an effective compliance program is to ensure there is an effective system for routine auditing and monitoring along with a system to identify compliance risks. You've established what you believe to be a solid audit plan for the year, but other things just seem to get in the way. First, you're tasked with researching the requirements for a new plan type. Then you have a fire to put out with a delegate. One of your staff gets a job offer she can't pass up, and before you know it, your audit schedule for the year is derailed. You'll get to them, right? Let's just hope you don't receive an audit letter in the meantime. With every passing Monday you hold your breath, all the while wondering how much time it will be before the inevitable occurs.
Sometimes an extra set of hands is all that's needed to get your audit activities back on track, but you do not have the budget for another full-time employee. Think of the following member-impactful audits that can be accomplished while you handle other responsibilities:
- Part C and Part D Grievances and Appeals
- Member Enrollment and Disenrollment
- Marketing
- Coordination of Benefits
All audit plans should include not only aspects included in CMS' protocol but also include audits of other self-identified areas of risk. Any operations that touch member service or payment might be considered higher risk on your assessment. Are they? And are you able to accomplish them all with the resources you have? Does your staff have the right skillset for the audits? From a CMS Q&A:
The safeguarding of beneficiary rights and protections is arguably the most important responsibility of a sponsor. Demonstrating you have the resources to detect, correct, and prevent occurrences of non-compliance is a struggle when a department lacks things like the time, resources, or skill to perform certain audits. Contact us for ideas on how we can partner with you to efficiently conduct some of your audits, providing you with some much needed assistance.
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The Centers for Medicare & Medicaid Services (CMS) audit practices have undergone a few changes in recent years, but the core focus remains the same: beneficiary protections. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more about our audit services >>
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
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Evolution Through Strategy: Pinpointing Growth Opportunities
My last article explained the choice of Medicare Advantage (MA) health plans to evolve or disappear. Evolution is certainly the preferable choice, so let's examine the steps needed to do so.
As with any company, you need to identify your target customer. State of the Art Membership accounting helps an existing determine strategies around expansion through a) new members (new to a company and new to Medicare) as well as b) the art of retention through pricing, quality and customer service. Both efforts are necessary to maintain a steady growth pattern. This is more sustainable than a membership spike up or down that will cause operational havoc and financial uncertainty.
Risk adjustment Adaptation follows the member through every clinical encounter. If not fully documented, inadequate risk adjustment practices mean money left on the table, which is not an option. Diligence and good provider relations with proper analytic tools are critical to support risk adjustment.
Proactive Member Service means caring about the member experience to set the stage for high level of care and high quality ratings. It helps with retention while ensuring maximum quality of care to the member as well as enhanced revenue from CMS to reward good service. The payback is healthier members who want to stay: a win — win situation!
Collaborative Accountable Providers represent a key partnership for the sake of the members. It is not always a natural alliance — different resources and priorities often conflict, but the health of the member through appropriate care management should be a common objective for both payer and provider. Various partnerships with providers to help with risk sharing is a new element that will offer advantages to both sides.
Make it Work Care Management focuses on the member's health as the single objective that requires proper and necessary medical care and ensures proper resources for the health plan to manage. The product design that attracts your membership base must also be managed to ensure a balance of quality for the member at the right price for the payer.
Finally, the partnership with providers is an integral part of the overall Mastery of Quality Ratings to maximize the outcomes as well as the member experience. CMS is serious about quality — it impacts enrollment opportunities, care management and member outcomes as well as financial performance through critical revenue bonuses and rebate opportunities.
Gorman Health Group has the expertise in all aspects of health plan operations to lead you through best practices but also how to leverage these steps into financial stability. With a proprietary pro forma model designed to quantify these areas based on an in-depth knowledge of MA best practices, we are able to lead management through the different strategic decisions and analysis to customize what works in your marketplace and how to leverage your own strengths. The goal is not just to survive MA but to evolve into something that will improve the community's health.
Join us next month to discuss how analytics can help manage these levers going forward to ensure success.
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On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
In a recent case study, GHG examined a mid-sized managed care health plan who struggled with poor MLR and how a cost-efficient affordability review that utilized trend management conducted by out integrated team of experts generated targets of $4 million in expected improvements. Download the case study here >>
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CMS Announces Expansion of the Medicare Advantage Value-Based Insurance Design Model
The Centers for Medicare & Medicaid Services (CMS) announced plans to expand the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model to more states and more conditions in 2018 without the experience of the first year's launch, which begins in January 2017. The schedule underlines the Administration's goal of rapidly expanding the use of innovative payment and delivery models that emphasize quality and good outcomes rather than volume of services. VBID models have been used in the private sector to better manage the costs and care of persons with high healthcare needs and the Medicare population, which has the largest number of persons with chronic care conditions, and offers the potential to see even better results for more people.
Under the demonstration, the requirement that the MA benefit package be uniform for all enrollees will be waived. The uniformity provision was adopted many years ago to ensure health plans did not use benefit design to exclude persons with conditions and disabilities requiring the use of many services and prescription drugs. Fortunately, over time, policymakers and plans have seen the value of programs that better manage the conditions of persons with chronic conditions, such as disease management programs, although participation has been lower than expected. The VBID model will allow MA plans to lower cost sharing, add services, and target providers considered "high value" for the selected chronic condition. MA and Part D plans will still be required to offer uniform benefits under the new model for all plan members with the target condition. As a beneficiary protection, participants in the VBID program can never pay more than other MA enrollees for their services or receive fewer benefits.
For 2018, the new states eligible to participate will include Texas, Michigan, and Alabama. Seven states and seven chronic conditions were selected for the first year of the demonstration. Participating plans will be announced in September 2016. The additional chronic conditions that will be available for VBID participants include rheumatoid arthritis and dementia. The second year model test program will allow MA organizations with at least one plan or a parent organization with one plan with 2,000 or more enrollees to offer VBID enrollment to other Plan Benefit Packages (PBPs) with at least 500 enrollees, thus expanding the number of participating plans and VBID participants.
CMS will conduct a webinar of the second year changes on August 24, 2016, at 2:00 pm EST. Participants may register at https://innovation.cms.gov/resources/vbid-2018changes.html.
CMS plans to issue a Request for Applications for the second year VBID model test program in the fall of 2016. Information on how to apply can be found at http://innovation.cms.gov/initiatives/VBID.
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From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Contact us today to get started >>
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Lessons on the Audit Front
The regulatory scrutiny continues. The Centers for Medicare & Medicaid Services (CMS) 2016 Compliance and Program Audits are in full swing, and it is readily apparent plan sponsors must be "audit ready." CMS' intent to hold plan sponsors accountable to comply with Medicare standards and ensuring beneficiary protection is evident. Plan sponsors must be ready to take the test.
It all starts with the data…make sure you get it right! The invalid data submission (IDS) was a condition added to the 2016 scoring methodology. CMS has emphasized the need for plan sponsors to validate all data submission before they are uploaded. The "Three Strike Rule" applies. If the sponsor fails to provide "accurate and timely" universe submissions twice, it will be cited as an observation in the audit report. After the third failed attempt, or if an accurate universe cannot be produced in fewer than three attempts due to missing or unavailable data, an IDS may be cited.
Speaking of audit scoring methodology, confusion appears to remain regarding the audit scoring method. Samples are no longer given a pass/fail score with a specified passing score of 95%. Issues are now identified as conditions. One condition may apply to multiple samples. CMS will evaluate the condition by the potential impact on the beneficiary as either an observation, Corrective Action Required (CAR), or Immediate Corrective Action Required (ICAR). The audit score is generated based on the number of non-compliant conditions discovered; the maximum audit score is unlimited.
Thus far in 2016, the most common conditions cited by CMS are ones we have seen before. Plan sponsors' failure to properly administer its CMS-approved formulary, usually due to a coding error by the Pharmacy Benefit Manager (PBM), remains a risk area. It is critical for plan sponsors to have an adequate oversight monitoring program to identify and remediate issues expeditiously.
Coverage Determinations, Appeals, and Grievances (CDAG) continue to be a low performer in 2016 CMS Program Audits. It is important for plan sponsors to connect the dots with end-to-end case preparation, and remember — nothing is off-limits. CMS can open any can of worms that is identified as a risk. Coverage determination notification letters remain a targeted area. Plan sponsors must have the necessary quality checks and/or oversight to ensure notification letters are specific to the enrollee's case, accurate, and provide the information needed to approve coverage in the case of a denial. This is a recurrent finding from prior years which CMS has cited in Best Practice Memos, so there is a low tolerance for inadequate denial letters.
New to the 2016 audit cycle is the Medication Therapy Management (MTM) Program Pilot Audit, which is conducted virtually in the second week. Despite the fact results of this pilot are not included in the plan sponsor's final report, CMS is not taking this audit casually. "The goal of this audit is to evaluate the implementation of the plan sponsor's adherence to its CMS-approved MTM Program," said a subject matter expert on our Pharmacy Solutions team. Be sure you are ready to tell the case story. "CMS has been particularly interested in looking at the continuity of care across plan years for members who received a Comprehensive Medication Review (CMR) in the previous year. This is one area which appears to be especially disconnected if plans may have had multiple MTM vendors or changed PBMs," continued Miller. "Coordination of information flow, especially for enrollee's year-over-year tracking, is essential." Plan sponsors that incorporate strategies for a ready state for CMS audit will be more successful. The conduction of an MTM Program mock audit is an effective way to identify shortfalls and issues in your data collection, accuracy, and overall readiness — before you are presented with a CMS audit engagement letter.
Another challenge noted in the 2016 audit front is, despite CMS process enhancements, auditor inconsistency. This presents a challenge in what a plan sponsor can expect. In order to be prepared for a program audit, plan sponsors should prepare by exceeding CMS' expectations, not just meeting them.
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Our highly structured mock CMS audit services are designed to replicate the latest CMS audit processes. Our team of industry veterans is ready to help your organization practice and learn the new CMS audit protocols; new universes and many more data fields, interviews via a webinar, and of course the CMS protocol documents. Visit our website to learn more about our CMS Mock Audit services >>
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Evolution or Extinction
"The Theory of Evolution has two main points," said Brian Richmond, curator of human origins at the American Museum of Natural History in New York City. "All life on Earth is connected and related to each other," and this diversity of life is a product of "modifications of populations by natural selection, where some traits were favored in an environment over others," he said.
This same theory can be applied to current healthcare. A health plan is the sum of various functions that deliver and monitor the beneficiary's care. The line between payers and providers is becoming more blurred as financial risks and quality measures are critical measures for all healthcare components.
The concept of evolution vs. extinction is quite real. Providers are looking at partnering with payers and taking on more financial risk to leverage the subsequent reward and help coordinate care. Payers are eager to have more control and visibility with providers as well as to follow beneficiaries through the continuity of care to manage shifts in income, demographics, and clinical needs over a beneficiary's lifetime.
As Medicare Advantage (MA) continues to cover almost one-third of the eligible population, new product trends are evolving.
Over the past four years, Health Maintenance Organizations (HMOs) dominate the marketplace with managed
care and tighter networks, but the recent duals demonstrations are recognizing demographic shifts as well as states moving to Medicaid expansion and better coordination.
Another predictor of the duals market is the Special Needs Plan's focus on duals as an at-risk beneficiary. A third driver is the stable Chronic Condition Special Needs Plan (C-SNP) market, which manages the clinical needs and provider partnerships. The Centers for Medicare & Medicaid Services (CMS) is expanding this concept further through the new Value-Based Insurance Design (VBID) demonstration starting in 2017.
Gorman Health Group has the tools and experience to help the healthcare community evolve and avoid extinction. Our feasibility model includes detailed financial projections and onsite strategy discussions to walk a plan through the entire process of entering MA or expanding current products and service areas with an emphasis on risks and rewards. We can then lead you through the product design and implementation phases to build a competitive and compliant organization with the proper financial and operational controls in place. Even existing plans need a new perspective to manage member retention, risk adjustment, and overall analytics to support an integrated care organization.
Let's build a more adaptable, efficient approach to healthcare! So standing still is simply not an option — the marketplace is moving due to changing competitors, regulations, and populations: evolve and adapt.
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In a recent case study, GHG examined a mid-sized managed care health plan who struggled with poor MLR and how a cost-efficient affordability review that utilized trend management conducted by out integrated team of experts generated targets of $4 million in expected improvements. Download the case study here >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
First Plan Preview of 2017 Star Ratings Data
It's official — the Star Ratings busy season is officially underway. The Centers for Medicare & Medicaid Services (CMS) recently notified plans of the first preview period for the 2017 Star Ratings data.
Although CMS did not introduce any surprises or unexpected measure changes as part of the first plan preview, plans have only a very short window to review their data for accuracy, with feedback due to CMS by August 18, 2016. Inevitably, some plans identify data issues or inaccuracies during this plan preview, so great care should be taken to validate each measure score and data element provided for review.
While the Healthcare Effectiveness Data and Information Set (HEDIS®), prescription drug event (PDE), and administrative measure scores likely contained no surprises for health plan leaders, the first plan preview data for the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) and Health Outcomes Survey (HOS) measures may contain some surprises. Improving performance on CAHPS® and HOS measures generally requires carefully planned engagement with both providers and members over a sustained period of time. With almost half of the annual member survey cycle already behind us, it is critical for plans to re-evaluate their current Star Ratings status to pinpoint high-risk CAHPS® and HOS problem areas in order to ensure the right activities are in place with the right members and providers to achieve desired improvements.
During the first plan preview, particular attention should also be paid to validating the Categorical Adjustment Index factor data, which will be used for the first time this year to account for the impact of socio-economic factors and disability status on quality measure performance.
Need assistance making sure your fourth quarter action plan is aligned with your highest risks or interested in assistance preparing for 2017? We can help. For questions or inquiries about how Gorman Health Group can support your Star Ratings program, please contact me directly at msmith@ghgadvisors.com.
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GHG's Star Rating team has been working on the critical factors that drive your Stars score for more than 15 years. Since the inception of the Star Bonus Program, we have supported dozens of clients, including small regional plans, multi-market players, and multiple Special Needs Plans (SNPs). We know what works and what doesn't, and we see where MA health plans continue to miss real opportunities to greatly impact their Star score. Visit our website to learn how we can help you with your Star Ratings program >>
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Medicare Advantage Pays Hospitals Less than Medicare
Researchers at Stanford University conducted a study of hospital payments by Medicare Advantage (MA) plans, Fee-for-Service (FFS) Medicare, and commercial insurers in 2009 and 2012 and found MA plans pay lower prices than FFS for most (but not all) types of admissions and in most (but not all) geographic areas. The study found:
- MA plans paid 8 percent less than FFS after adjusting for diagnostic-related group (DRG) and geographic area differences between MA and FFS.
- If differences in hospital networks are also taken into account, MA plans paid 5.6 percent less than traditional Medicare. Thus, about one-third of the 8 percent difference in MA and FFS prices is attributable to narrower MA networks.
- MA plans in areas with the highest FFS spending paid lower hospital prices than MA plans in areas with the lowest FFS spending.
- MA plans with the highest enrollment penetration rates paid lower hospital prices compared with MA plans in areas with lower MA penetration rates.
- MA plans pay less for admissions with short lengths of stay.
Commercial insurer rates were much higher than either MA or Medicare FFS rates. Commercial plans pay higher prices than FFS for almost all types of admissions in almost all geographic areas. Higher FFS spending was associated with lower commercial prices.
The researchers (Laurence C. Baker, M. Kate Bundorf, M. Devlin, and Daniel P. Kessler) undertook the study because the literature provides no systematic analysis of the unit prices MA plans pay relative to FFS payments and whether lower MA costs are due to lower quantities of services per patient, lower prices per treatment, or both. According to the researchers, the conventional wisdom is MA plans save costs by lowering the quantity of services, and MA plans pay more to providers because they lack the FFS monopsony purchasing power. The study concludes at least part of the cost advantage of MA plans is due to lower prices and not lower quantities than FFS.
The researchers recommended Medicare consider the market environment more broadly than the level of FFS spending when setting MA payments. The researchers also recommended FFS payments to hospitals be adjusted across geographic differences and DRGs to better reflect the market.
The study used the Centers for Medicare & Medicaid Services (CMS) FFS data on all hospital payments and claims data for patients from the Health Care Cost Institute (HCCI), which represents 27 percent of the non-elderly population and 31 percent of the elderly MA population. The actual hospital prices negotiated with plans were not available since they are considered proprietary.
The study methodology used the average price per admission across metropolitan areas adjusted for differences in hospital networks, geographic areas, and case mix. To account for case mix, the researchers used only the DRG pairs that were common to MA and FFS. The researchers noted several limitations to their study findings, for example, HCCI claims data are not identical to the national distribution of MA and commercial enrollees and do not capture unobserved differences in patient severity across insurers, e.g., MA and commercial hospital admissions may be more severe than FFS admissions due to prior admission and prescreening.
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GHG can assess the alignment of your products, your current network, your market, and your network requirements. We'll help you track results — both positive and negative — back to related network components. From there, we assist in developing and executing a networking strategy, from contracting targets to model contract terms, to payment terms that match your budgets and the capabilities of your claim payment systems. Visit our website to learn more >>
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Complaints — Make Sure They Are the Gift that Keeps on Giving
Have you ever received a gift you knew had value, but you just weren't sure how to use it to its full potential? Complaints are very much like that. We need to change our view of complaints and consider them to be gifts from our members that need to be opened and cared for as the important pieces of information they are. Complaints are something we all wish would never be needed, but every health plan receives them. Our members have needs, and sometimes those needs don't appear to our members to be met. In those instances, if we are lucky, the health plan receives the complaint. If we are not lucky, our members' neighbors, acquaintances, doctors, or even worse — regulators and congressional representatives' — receive the complaint.
Regan Pennypacker, Gorman Health Group's (GHG's) Senior Vice President of our Compliance Solutions Practice says it best, "Complaints, grievances, expressions of dissatisfaction — these are a part of life in the course of running any government program. The processes are in place to provide an avenue for your membership to speak openly about their dissatisfaction and provide you an opportunity to take that data, analyze for trends, and, if possible, make changes in an effort to improve quality."
Here are four components for making the most of that opportunity:
- Train staff to hear complaints. There is a delicate balance in Customer Service to identify complaints. Some Customer Service staff members are so focused on fixing the immediate issue, they don't recognize the additional complaint concerns. An example of this is a member calling to change his or her primary care physician (PCP) because things are "not working out with this provider." It is easy and beneficial to help the member change to a new PCP, but what is the underlying issue that needs to be explored? If the health plan doesn't know what is going on, there is no way to resolve the matter for this caller or other members. Having staff trained to recognize when a complaint is presented is the first key step to successful complaint management.
- Correct categorization of complaints. This is an often discussed topic as it is a high audit risk and a frequent audit finding. A complaint is identified, but what type of complaint is it? Customer Service is often the first to talk to members about their concerns. Sometimes the call is an inquiry or an educational opportunity or a misunderstanding that can, with the right information, satisfy a member. Other times the call is regarding a complaint that is an appeal, grievance, coverage determination or organization determination, or a combination of several types of complaints. Ensuring knowledgeable staff and clear support tools are in place to correctly categorize those complaints allows members' concerns to be heard and addressed and appropriate due process to occur. If a member calls to complain about wanting but not being able to get a specific medication, that will most likely fall under a coverage determination or appeal if it was previously denied by the plan. Obtaining all the details will allow for a thorough and correct determination. What if it is a provider who was not willing to discuss any other formulary options, even if the member explained the drug makes the member sick? Possibly there is a quality of care grievance that needs to be explored; carefully categorizing a complaint is the next critical step in processing complaints.
- Empowered, knowledgeable staff who can thoroughly investigate the complaint. Regan summarized this well, "Skilled, knowledgeable, empowered grievance and appeal coordinators are key drivers in plan satisfaction. Yes, the complaints will still come in, but what are you doing about them? How are those addressing grievances empowered to turn that interaction into a positive customer experience?" Some of my greatest product loyalty has been developed when I called to complain about an issue, and the company representative listened, investigated, and resolved the issue. It wasn't always resolved in the manner I wanted, but I knew I was heard and that what could be done was done. People processing complaints have to understand the importance of a complaint reported to the plan and be empowered to manage that complaint in the highest customer-focused manner.
- Tracking, trending, and root cause analysis. Often times there is a disconnect between all the information gained from complaints and ways to make that information useable to improve processes and quality. Most plans track their complaints and report them to the Quality Committee. Some plans analyze the information searching for trends that can be managed and processes that can be improved. They look at the root cause of the issue that caused the complaint to see what can be done differently going forward. They evaluate the data to see who else might be impacted and proactively work to remediate the situation. They truly see the value of the gift provided to them to improve their organization.
Complaints are like constructive criticism: hard to hear sometimes, but they can make a big difference going forward. Just as it takes a strong person to adapt to constructive criticism, it takes a change in culture to value complaints as an opportunity to change and improve. Finding the worth in your members' complaints will make your plan a stronger, more customer-focused organization. Does your organization leverage the complaint gifts you receive and make them count? If not, you are losing a key opportunity on a gift you already have and just don't know fully how to use.
At GHG, our consultants have worked in the weeds. We understand the processes and pain points health plan staff face on a daily basis. We are here to help you as you evaluate your program and adapt to an ever-changing environment. I would welcome the opportunity to talk to you about how we can assist your organization as you strive towards more compliant and efficient operations.
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At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
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Aligning With MACRA: Infrastructure And Initiatives That Yield Results
The Centers for Medicare & Medicaid Services (CMS) had almost 4,000 responses from providers and health plans regarding the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). With almost 1 million provider groups potentially impacted by the proposed rule, small groups and individual practitioners (primary care physicians (PCPs) and specialists) are being forced to think of their medical practices as a real business. Most of these providers do not have the robust infrastructure compared to their clinical counterparts that fall into the Alternative Payment Model (APM) buckets — Accountable Care Organizations (ACOs), Independent Practice Associations (IPAs), or Clinically Integrated Networks (CINs).
In order to align with the proposed legislation, demonstrate quality, report data, and position the medical practice for shared risk programs, the providers who fall into the Merit-Based Incentive Payment System (MIPS) bucket will need to make some critical decisions. That is if they actually want to realize a positive Return on Investment from participating in the program.
Keep in mind, the following will apply to PCPs and specialists alike:
- Revamp and deploy a data strategy that reconciles and reports patient-level data across multiple delivery systems and sources. Data integrity, quality, and accuracy will make or break a practice's success. It will get worse before it gets better, but everything can be fixed.
- Conduct a comprehensive chart review and risk adjustment program analysis, collecting the baseline health and condition statuses for your attributed patient panels and evaluating the coding patterns of your clinicians with diagnostic authority (Physician Assistants, Nurse Practitioners, Medical Doctors).
- Build and implement a Quality Oversight and Operations work plan that oversees the delivery of superior patient experience activities and aligns clinical practice models with imposed Clinical Quality Metrics.
- Bridge the communication with consulting specialists and network health systems and mid-level clinicians to coordinate care, make informed clinical decisions, and avoid redundancies in care that historically incur unnecessary medical expenses (which would carve into any anticipated financial benefits that were forecasted at the onset of any risk-based payment model).
The way I see it, if the proposed legislation moves forward, providers will have the following choices:
- Join an established APM, like an ACO or a CIN (if they'll have you)
- Jump in with both feet and make a HUGE investment in the infrastructure outlined above
- Find "MIPS friends," create consortiums, IPAs, and other qualified practice models that meet the CMS criteria
- Become an employed provider in a health system or academic medical center
- Transition to a concierge medical practice model and succeed
Gorman Health Group's experienced team is currently working with the provider, health system, and health plan communities to determine the best approach to achieve success. This is not a one-size fits all program, and Gorman Health Group can help find the most realistic, effective, and actionable approach for you and your organization.
Please contact me directly at dweinrieb@ghgadvisors.com or at 202.774.8016.
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What will the consequences of MACRA be? Will the money at risk motivate physicians to be more efficient? Or will it lead them to shun traditional Medicare patients? Read more in another article recently published on the GHG Blog >>
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