The Path to Value: The MACRA Quality Payment Program
To quote Yogi Berra, "If you come to a fork in the road, take it." Great, but exactly which fork do I take when faced with multiple options? That is the question many provider-led organizations are asking today.
On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) unveiled key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a bipartisan legislation that replaced the Sustainable Growth Rate (SGR) formula with a new approach to paying clinicians for the value and quality of care they provide. The proposed rule would implement these changes through a unified framework called the Quality Payment Program (QPP), which includes two paths.
To the left, we have the Merit-Based Incentive Payment System (MIPS), and to the right, Advanced Alternative Payment Models (APMs). So what is a doctor or medical group to do at these crossroads?
The MIPS path leads to a world where a percentage of Fee-for-Service (FFS) Medicare payments are at risk based on performance in quality measures in four areas: Quality, Use of Information Technology, Clinical Practice Improvement, and Cost. Measurement would begin in 2017, and the rubber hits the road in 2019. By 2022, the portion of reimbursement at risk will be at 9% and could go beyond that. "MIPS is going to be the "new norm" for providers," said David Sayen, Senior Vice President of Client Relations at Gorman Health Group. "There will be no more hand wringing about draconian cuts to physician payments and, per Kerry Weems' clever quip, no regularly scheduled annual hostage taking."
However, it is important to keep in mind this is a zero sum game. To pay off the winners, there have to be losers, and nobody wants to be a loser. So we head to the other fork, which appears to have sunny skies and bluebirds just over the first hill. First, there is a hill. Moreover, for those providers who are starting to round the corner and take their initial steps into value-based risk sharing arrangements, it is never too early to start thinking about the right path for you and your organization.
For those providers who have taken a few steps or even large strides down the value-based fork and have a good understanding of their quality/cost compared metrics, have tightened their belts, and have a good understanding of contracting and negotiating risk sharing arrangements with payers, to get over the hill, you have to get onboard the APM train. Through future rulemaking, CMS will determine which APMs are acceptable as alternatives to MIPS and will be looking for models that have risk components as equally robust as MIPS.
We now know the Medicare Shared Savings Program (MSSP) Tracks 2 and 3 have been identified as APMs and would be exempt from MIPS payment adjustments. Additionally, they would qualify for a 5% Medicare Part B incentive payment. To qualify for incentives, clinicians would have to receive enough of their payments or see enough of their patients through Advanced APMs. Currently, only 5% of the 433 MSSP Accountable Care Organizations (ACOs) are participating in Tracks 2 and 3. However, the other 95% are gaining the experience they need to make actionable decisions on which fork their organization needs to move towards to prepare for the changes.
For organizations interested in taking the step towards forming a Medicare ACO, and potentially having the opportunity to participate in the QPP as an MSSP Track 2 or 3 via the Advanced APMs, the time for action is now. Your MSSP Notice of Intent to Apply is due May 31, 2016. Gorman Health Group (GHG) is available to help you understand the current MSSP requirements and your organization's readiness level. With the proposed changes to resetting the benchmark to incorporate factors based on regional FFS expenditures to establishing and updating the ACO's rebased historical benchmark, including an adjustment to the benchmark based on regional spending that is phased in over several agreement periods, GHG can assist in identifying health cost trends that vary in communities by using regional spending growth trends. As your organization makes the cultural shift towards a value-based model and establishment of essential ACO functions, we can assist in identifying priorities and goals for each functional area and developing a plan that is actionable, from the first step in applying to be an MSSP through implementation.
MSSP applications are due no later than July 29, 2016, at 5:00 p.m. EST. Please feel free to reach out to GHG for assistance in navigating the application. Alternatively, if you are a provider organization that would like to talk through key questions to ask prior to entering into a risk contract, we can help there, too.
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Why are the Dual Eligible Demos Such a Hot Mess?
There's no avoiding the steady stream of bad news facing the Centers for Medicare & Medicaid Services (CMS) financial alignment demonstrations for dually eligible beneficiaries. Enrollment is declining, beneficiaries are opting out at epic rates, and leading states like California are slowing their efforts despite crushing budget realities. Dozens of health plans have invested millions to participate in what's become a hot mess. Where do we go from here?
An early priority of the Affordable Care Act was to give states great flexibility in transitioning dual eligibles into health plans. Back in October 2013, over 60 participating health plans began enrolling dual eligibles through three-way capitated contracts with 13 states (VA, MA, IL, OH, CA, TX, SC, MI, NY, MN, CO, WA, RI) and CMS, representing a $40 billion annual revenue opportunity. After a strong start through the first half of 2015, the pilot programs for the most vulnerable patients in the U.S. health system started hemorrhaging. Net enrollment has declined for the last 4 months. Overall, only 30% of eligible beneficiaries are enrolled — way below expectations. The demos have been plagued by beneficiary opt-outs over 70% in some states, scared off by anti-managed care providers and advocacy groups. In some states, over one-third of eligibles "simply can't be found."
Some of these issues, like difficulty in locating dual eligibles given their widespread transiency, come with the territory and call for a much more aggressive community-based outreach and education campaign by state officials prior to the launch of these demonstrations. High rates of opt-outs show that outreach also must include providers and advocacy groups, especially those for the disabled, who "defined the terms of the debate" with beneficiaries and talked them out of participating before launch. One advocate noted, "Seniors have many doctors because they have multiple chronic conditions. Even the thought of losing a physician … is enough not to sign up."
Last year, CMS conducted an independent analysis of the state demos, which found that states didn't realize how much it would cost to implement, especially in IT infrastructure. They found huge issues with enrollment, despite a phased approach, and found health plans had a hard time keeping up with basic reconciliation, coverage and payment transactions. With this came the issue of trying to find beneficiaries to complete their initial health assessments and to educate them on the benefits of the demo in the first 90 days of enrollment. Large-scale demos, such as in Los Angeles County, were plagued with problems, whereas less ambitious launches went more smoothly. This argues for more 1915(c) home and community-based services waivers on a smaller scale and less monster 1115 waiver projects.
But the fundamental issue remains — the enrollment process —and here is where policy must change. Focus groups show that more than 40% of opt-outs were unaware they had done so — this in a state where 89% of enrollees are satisfied with the program once they are in it. This argues that voluntary enrollment is counterproductive to the goal of enrolling dual eligibles in coordinated care. Massive community-level outreach to beneficiaries, advocates, and providers must be required and paid for, followed by passive and/or facilitated enrollment processes that automatically enroll beneficiaries into plans unless they affirmatively choose otherwise. Anything less only results in pilot projects that fail to thrive.
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More than 200 health plan clients and an additional broad range of other industry participants each year trust Gorman Health Group's team of professionals to deliver expert counsel and tools to help them meet their goals. We pride ourselves on having both day-to-day alignment with the latest CMS guidance and the long-term strategic vision to keep it all in perspective. Contact us today >>
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Tag, You're It…RADV Selection Has Begun
The data submissions have been completed, and the Risk Adjustment Data Validation (RADV) selection process has begun. Are you prepared for what the RADV has in store for you? In April 2016, the U.S. Government Accountability Office (GAO) released a report titled, "Fundamental Improvements Needed in CMS's Effort to Recover Substantial Amounts of Improper Payments." This report is quite telling about the improvements needed to strengthen payment recoveries during a RADV audit. John Gorman highlighted in a previous blog, "[the Centers for Medicare & Medicaid Services] CMS is on pace for its most aggressive enforcement year ever." So if you are one of the lucky plans that has an Affordable Care Act (ACA) plan and a Medicare Advantage (MA) plan selected for the RADV audit, my hat's off to you because you are about to experience not one but two risk adjustment audits this year.
For those plans selected for the RADV audit, now is the time to grab your RADV readiness plan off the shelf, dust it off, and put it into action. With a very short time frame allotted for health plans to request, review, and submit the appropriate documentation to support a Hierarchical Condition Category (HCC), there is no time to waste. There are five important pieces needed to survive a RADV audit:
- Accountability — It is important all employees involved in the RADV audit know who the person is within the company who is accountable for ensuring the RADV audit is conducted appropriately within the time frame allotted.
- Communication — All departments need to talk consistently during the audit process because of the short time frame to deliver the best supporting documentation available.
- Validation Review — Chart reviews should be conducted and documented in accordance with your health plan's Coding Guidelines and Compliance RADV Policy.
- Dispute and Appeal — Know when and how to dispute or appeal a finding from CMS.
- Lessons Learned — When it's all said and done, most importantly, learn from your mistakes and make strides to improve to prepare for the next audit.
If your health plan was fortunate enough not to be selected, congratulations to you for dodging the RADV selection process this year. Try not to get too comfortable with not having to participate in the RADV audit. CMS' goal is to have all MA plans subject to an annual RADV audit, comprehensive or condition-specific. It will take time to get to this point, but be aware a yearly RADV audit is right around the corner for MA plans.
There is no need to sweat over being selected for a RADV or the potential change to an annual all health plan participation audit. Reason being, everything you are being audited on is information that was submitted by the health plan to CMS. You can't necessarily plan for all of the unknowns or anomalies that occur during the audit, but you can certainly plan for the knowns. Health plans have the ability to ensure data quality and integrity with the risk adjustment operations that are in place prior to the data submissions to CMS. With all of the recent press and discussions about MA overpayments, health plans need to be assessing their risk adjustment internal controls. These are the primary categories for which health plans should be ensuring the right policies and processes are in place:
- Risk Adjustment Oversight — Various departments within a health plan should be providing oversight on the data submissions and operations of risk adjustment.
- Provider Engagement — Strong physician partnerships and collaboration are needed to build a long-term strategy around HCC validations.
- Risk Adjustment Interventions — Health plans need to have clear guidelines on acceptable supplemental diagnosis information obtained through interventions.
- Vendor Management — The vendors with whom health plans contract are an extension of the company. No matter how much you utilize a vendor to run your risk adjustment operations, they are not accountable to CMS during a RADV audit.
- RADV — Have a readiness plan in place and be ready to go upon being selected for the audit.
Health plans should be conducting operations as if an annual audit will occur, regardless of whether the plan is selected. There is no time like the present to ensure your health plan's risk adjustment operations are in order.
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GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>
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The Effect of the New Part B Drug Payment Proposal on Medicare Advantage and Part D
It's no secret drug costs have skyrocketed in the past decade, and drug payment policymakers face an uphill battle in figuring out how to curb this exponential growth. The Centers for Medicare & Medicaid Services (CMS) has already taken a beating on its proposal to test a new alternative payment design to pay for drugs covered under Medicare Part B, calling into question whether this new methodology will go through looking anything like originally proposed. Part B spending is just a fraction of drug spending in Medicare, covering the drugs administered by a physician or hospital outpatient department. A major question for our industry is what effect this new proposal will have on Medicare Advantage (MA) and Part D plans if implemented.
Part B spending on drugs has increased annually by 7.7% since 2005. Currently, most Medicare Part B drugs are paid using the Average Sales Price (ASP) plus a statutorily mandated 6% add-on. This creates an incentive to prescribe more expensive drugs due to the higher payment amount. Under the new model, Medicare Part B would pay the ASP plus an add-on of 2.5% and a flat fee of $16 per drug per day. The lower add-on and inclusion of the flat fee would decrease the incentive to provide more expensive drugs as the revenue for the drugs would be more evenly distributed. CMS will then roll out the second part of the experiment in which they will test several other pricing methodologies currently utilized by commercial health plans and pharmacy benefit managers, such as discounting or eliminating cost-sharing, providing feedback on prescribing patterns and decision support tools, basing pricing on a drug's clinical effectiveness, and setting benchmarks for a group of therapeutically similar drug products.
The industry was quick to respond, arguing the proposal will lower incentives to give beneficiaries access to vital drugs due to the cost, leading to a reduction in patient outcome as well as patient satisfaction. Some physician groups threatened, if this new payment methodology doesn't adequately cover the cost of the drug, a physician would opt not to prescribe the more expensive, even if more appropriate, medication. The proposal is also facing much scrutiny from both sides of the aisle in Congress, although some Democrats did offer their support. The House and Energy Committee will hold a hearing on the demo on May 17, 2016, along with a bill aiming to quash the demo entirely.
We probably won't see a similar proposal under Part D, as CMS argued it is actually using some of the principles of Part D to inform their payment methodology in Part B. However, as America's Health Insurance Plans (AHIP) pointed out in their comments to CMS, this proposal would likely have some significant downstream effects on MA and Part D plans. AHIP noted the historical tendency of a reduction on pharmaceutical prices in one market segment to lead to cost-shifting practices by manufacturers, such as setting higher prices for new drugs and higher drug price increases for existing drugs. MA and Part D also lose out because they lack the flexibilities of the new value-based tools proposed under Phase II that could also benefit MA and Part D plans. The rollout of the new model could also the affect MA and Part D bid process for 2018, due to the cost-shifting effect of the proposal.
CMS has already noted it will seriously consider making changes to the proposal. For example, CMS announced it will re-examine whether certain types of practices would not be adequate enough to cover certain types of drugs — such as small rural oncology practices. We could also see CMS propose an alternative tiered approach instead of the ASP and add-on formula. CMS is also considering excluding the new oncology care model from this proposal. Despite these changes, questions as to the effect on the remaining Medicare drug programs remain.
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Are Your Members Giving Your Plan A Thumbs Up?
It's that time of year when health plans are designing their benefit packages for the upcoming selling season, setting goals for their sales team, and implementing strategies to achieve greater success than the year before. But have health plans lost sight of what really matters to membership growth? Are health plans thinking about their current members while planning for their future members? If not, you should know each retained member contributes an incremental amount annually. Do you know the impact of a single member?
Member retention is key to long-term success. Net growth does not happen with new sales alone but with a careful balance between new sales and the retention of members once they have enrolled. Plans can meet all sales goals and still end up significantly below membership and revenue targets if members disenrolll from the plan.
Members leave a health plan for a variety of reasons, including dissatisfaction with the health plan, the product, provider access, misinformation/marketing abuse, cost sharing too high, and service or quality of care, but the majority of disenrollments are within the plan's control.
Dissatisfied members may enroll into a competitor's Medicare Advantage or Part D plan, a Medicare Supplement, or return to Original Medicare coverage. Proactively addressing factors which lead to member disenrollment should be the focus of any member retention effort.
What is a member retention program? A member retention program encompasses member engagement, satisfaction, and performance measures. A successful program should be geared around the relationship between the member, the plan, and trusted advisors.
Careful design of retention initiatives and a commitment to communication will deliver a significant and positive impact on enrollment and revenue generation. The foundation of an effective member retention strategy is cross-functional alignment, placing the member at the center of the health plan's initiatives and core business functions.
Sales and Marketing typically are responsible for attracting new members and keeping them engaged during the onboarding process, but a true retention strategy contains efforts from all disciplines inside the health plan. No one department can be responsible for the full engagement of a member. Once a member is part of the health plan, they touch Customer Service, Communications, Risk Adjustment, Care Management, Compliance, and Operations. Their experience in all of these aspects of the health plan drives the retention of that member which in turn helps health plans increase Star Ratings and helps the health plan reinvest their performance bonuses in more and better member benefits.
Utilizing our cross-functional expertise, Gorman Health Group can work with your health plan to create a customized retention program focusing on strategies that address key factors driving your disenrollment and negatively impacting revenue.
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
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Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit.Visit our website to learn more about our services >>
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Latest Sherlock Benchmarks Confirm Medicare Advantage is a Miserable Beast to Manage
The geniuses at Sherlock Company, whose benchmarks on health plan administrative standards are considered the gold standard, have released their 2016 findings and the numbers paint a clear picture: Medicare Advantage (MA) is a miserable beast of a product. It's complicated and labor- and capital-intensive, requiring tremendous patience for executives and investors alike.
First: Sherlock's benchmarks confirm that MA requires nearly double the staff per 10,000 members as do commercial group products, and nearly triple that of Medicaid managed care. Much of this staffing is driven by unique requirements in the "Account and Membership Administration Cluster" (Enrollment / Membership / Billing, Claim and Encounter Capture and Adjudication, Customer Services, and Information Systems.)
Second, successful MA management requires big investments and, above all, patience. Sherlock found investments in Medical Management, Star Ratings and Sales/Marketing in Medicare takes at least a year, and often much longer, to show results.
Third, Sherlock demonstrates seniors are high utilizers of customer services relative to all other insured populations, and low costs are not optimal costs. Plans that spend little on service typically suffer worse member retention, membership growth, and customer satisfaction. MA members have longer service handle times, higher appeal rates, much higher rates of claims inquiries, and are less likely to utilize automated call systems.
The upshot? Once you master MA, all other lines of insurance business are a walk in the park in comparison. If this was an easy business, we'd be out of business.
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More than 200 health plan clients and an additional broad range of other industry participants each year trust Gorman Health Group's team of professionals to deliver expert counsel and tools to help them meet their goals. We pride ourselves on having both day-to-day alignment with the latest CMS guidance and the long-term strategic vision to keep it all in perspective. Contact us today >>
Under the provisions of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), physicians and other practitioners will face a Hobson's choice: live with a more aggressive risk-based adjustment to payments or join forces with an alternative delivery model, like an Accountable Care Organization (ACO), that is taking risk. Read the full article >>
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What a Clinton Administration Could Mean for Government Health Programs
So the people spoke and we are heading for an epic cagematch smackdown general election between reality TV star Donald Trump and former Senator and Secretary of State Hillary Clinton. And you're asking, what's going to happen to Medicare, Medicaid and ObamaCare? The answer is plenty -- below the waterline and out in the states. Stakeholders will need to pay attention or get left behind.
First, the likely scenario is that Hillary is going to win this thing big. While other Republicans may have had a chance to capitalize on her high negatives with likely voters, nobody's negatives trump Trump's. He's the most unpopular major-party candidate since polling began. Most polls have him losing by double digits in November.
At this moment, Trump's likely to lose so bad that many down-ticket Republican Senate and House seats are now in play. So: Hillary in the White House, Democrats likely running the Senate again, and poor Speaker Paul Ryan trying to corral an even more radical, noisy and smaller Tea Party caucus in the House. The only people those guys hate more than President Obama are the Clintons. So betting on more gridlock is safe money. Little or nothing gets done in Congress except the bare minimum to keep government running.
That means most of what happens in Medicare, Medicaid and ObamaCare will occur "below the waterline" in Administrative policy, regulation, and guidance, or is driven by the states. Here's what that could look like:
- Medicare: the forced march to value-based payment across the program will continue. The recent MACRA rule makes it clear that a fundamental change to traditional Medicare is coming and that fee-for-service is dead. By the end of Hillary's term, a majority of Medicare dollars will be tied to provider performance. Medicare Advantage will continue its steady 5-7% annual growth and exceeding 25 million enrollees in 2020. But CMS raises the bar through a rapidly-maturing Star Ratings program and an aggressive compliance and auditing initiative carried over from Obama's last year in office. Regulations and guidance are pumped out in regular order, drafted by newly-emboldened career CMS staff and making the program a laboratory of continuing performance improvement with claws and teeth.
- Medicaid: on the heels of the biggest regulation in 12 years, Medicaid converges more than ever with Medicare Advantage and ObamaCare, but also goes down some very strange alleys. With Obama out of office, several more red states like OK and TN finally take the Medicaid expansion deal from the Affordable Care Act. But with it they insist on "conservative principles" like work requirements and drug testing that dampen coverage and introduce new complexities to the program. At the same time, blue and red states alike flood CMS with new home and community-based services waivers to force dual eligibles into health plans and implement managed long-term care programs.
- ObamaCare and health insurance exchanges: health plans in the public exchanges continue a market correction and shakeout for another two years. During that time, CMS issues even more regulations dove-tailing exchange operations with Medicare Advantage rules, and several states currently running their own marketplaces like CO revert to healthcare.gov.
Health plans and other stakeholders in these programs will need to pay more attention than ever to stay ahead as government solidifies its role as their biggest customer. These are changes that won't necessarily be splashed across major media, but rather in trade rags and expert blogs. The only thing that's certain: it won't be dull.
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The Centers for Medicare & Medicaid Services (CMS) issued the final Medicaid "mega-rule," a huge regulation that makes changes to every part of the current managed care rules. Read more >>
Under the provisions of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), physicians and other practitioners will face a Hobson's choice: live with a more aggressive risk-based adjustment to payments or join forces with an alternative delivery model, like an Accountable Care Organization (ACO), that is taking risk. Read the full article >>
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An Important Component of MACRA: Quality Measures Development Plan
The Centers for Medicare & Medicaid Services (CMS) recently released a proposed regulation that will implement the payment incentives through the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). An important component of these new incentives is the Quality Measure Development Plan (MDP), which CMS finalized and posted this week. The purpose of the MDP is to create a strategic framework for the future of quality measure development to support MIPS and advanced APMs.
Under MIPS, clinicians will see a payment adjustment beginning in 2019 based on their performance score across four performance categories: quality, resource use, clinical practice improvement activities, and advancing the use of information technology. Under advanced APMs, payments must be tied to quality measures comparable to those quality measures used under MIPS. These quality measures will be developed by CMS by November 1, 2016, as required by MACRA, and CMS will utilize this new MDP to guide the development and implementation of these new measures. CMS currently has an ongoing solicitation to stakeholders to assist in finalizing the initial set of measures.
CMS will also incorporate the seven core measure sets recently released by the Core Quality Measures Collaborative, a partnership between America's Health Insurance Plans (AHIP), CMS, and other industry groups. The plan notes its focus on coordinating with federal agencies and other stakeholders in order to lessen the duplication of efforts within the industry and promote person-centered healthcare.
The MDP notes current known measurement and performance gaps and solutions to close these gaps through new quality measures. For the first measure set, the MDP posted the initial priorities for measure development in six quality domains: clinical care, safety, care coordination, patient and caregiver experience, population health and prevention, and affordable care. CMS will update the MDP as they identify new gaps in measurement and performance in order to develop additional quality measures annually.
In reviewing the recent MACRA legislation for potential changes, and putting together comments to CMS, organizations should also carefully review the new Quality MDP in order to ensure their comments are incorporated into the release of the first set of measures by November 1, 2016.
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CMS recently released the proposed rule that sets forth the replacement for the Sustainable Growth Rate (SGR) formula and creates the new payment system based on value rather than volume. Daniel Weinrieb, GHG's Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, along with our team of experts will provide a detailed analysis as well as industry recommendations. Stay tuned!
What Is Driving Growth in Your Plan?
It's May, so if you have not formalized your sales and marketing strategy for this Annual Election Period (AEP), now is the time. At our recent Gorman Health Group 2016 Forum, Carrie Barker-Settles and I had a very insightful discussion with Forum participants about what is driving growth in plans today.
First, membership data analysis. It is critical to understand your data in order to understand the following about your members:
- What are the geographic, demographic, and plan selection of new members in the last year, and which plan, marketing tactic, and sales distribution did they come from?
- You need the same information about voluntarily termed members and any additional data gleaned from survey data.
Next, it is important to conduct a market analysis to review the following:
- Medicare population and penetration
- Product and plan trends
- Benefit design analysis — looking for product and benefit innovation
- Multicultural diversity
- Competitive analysis and trends
With this information, you should have a strong idea of what your growth looks like — now you need to understand how to attract it going forward.
Whether or not you are currently attracting the aging in audience, you want it! Having a young Medicare beneficiary helps drive down costs. But Medicare beneficiaries are beginning to delay retirement, so developing strategies to capture these folks is probably the most cost-effective program you will have, and having a benefit design that is attractive to this market is critical.
When trying to attract the younger Medicare beneficiary, the Affordable Care Act (ACA) enrollees aging into Medicare will be a strong market — if you are in the ACA market segment. Plus, you have the opportunity to target enrollees with "like" plans and just enroll them without having them test the outside waters, if you do it correctly. In addition, this audience is much more attuned to social and online media. We have found there are online media tactics now entrenched in most media plans, but testing should be continuous since more members will begin to enroll online who have purchased their ACA healthcare online and will expect the same experience with Medicare.
"For continued growth in your plan, make sure you're leveraging a multi-channel strategy to achieve your sales goals," said Carrie Barker-Settles, Gorman Health Group's Director of Sales & Marketing Services. "Placing too much emphasis on one channel may result in unsavory consequence. Utilizing the right channel for the opportunity will enable you to reach prospects that don't respond to the standard marketing outlets and help achieve the stretch goal that the sales team is always faced with year after year."
When looking at the sales channel, this segment continues to diversify.
First, there are the Transition Managers or "Navigators" − Distribution of direct-to-consumer Medicare products to support commercial companies transitioning their members from group plans to defined contribution individual plans. We have seen this segment grow substantially in the last few years.
In addition, we are beginning to see some transition among plans regarding their sales distribution of contracted agents, captive agents, and employed agents, and mixtures of all of the above with telesales and online sales. Another segment we see gaining popularity is storefronts. Have you reviewed your strategies among those discussed here today? If not, make sure you understand from where your opportunity for growth for 2017 will come. Believe it or not, 2016 is coming to a close quicker than we think.
If you need help in evaluating your marketing and sales strategies, let us know — we are here to help!
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Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more about our services >>
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50/50 Just Won't Cut It — You Have to Commit 100%. The Top 5 Components for Successful, Compliant, Committed Operations
If you weren't able to make it to the Gorman Health Group 2016 Forum this year, you missed a dynamic time. More than just relevant topics, it included engaged participants who added a wealth of depth to our discussions. The topic garnering a lot of audience participation was "Can Operational Efficiencies and Compliance Co-Exist?" The struggle to align the two is real and takes constant, diligent effort, but the success it can create is priceless.
I told a story about a recent vacation involving a shark swimming in the surf. At one point it started swimming towards a father and son. Those of us on the pier were yelling to warn the man to leave the water, but he couldn't hear us. It wasn't until the people on the beach carried the message to the man that they got out of the water. Oftentimes we rely on the Compliance Department to carry the weight of maintaining compliance, but like the people on the pier, that message only goes so far. To be effective and make a real change, the message has to be embraced by everyone in order to make a real difference.
Here are the five critical points to ensure operations entwines compliance in its core:
- Don't Ignore the Human Factor — Our employees are the most critical factors in our department's productivity and compliance. Make sure our employees are well trained on not only the technical components of the job but on the critical compliance requirements as well. Employee engagement, like member engagement, is critical to success. Our employees want to do a good job, but sometimes they don't fully understand all that success entails.
- Know the "Why" behind an Action — What vision have you imparted to your staff? Are they just keying in applications, or are they setting up and welcoming members into your plan? Do your employees think compliance is an obstacle to be circumvented or a process to be embraced? Making that transition occurs by showing the "why" behind the action. How does what they do, both individually and as a department, impact our members? What is the logic behind why the Centers for Medicare & Medicaid Services (CMS) requires that activity? What they do is important, and making sure they understand all the reasons why makes your vision their vision.
- Have the Right Tools — Manual work-arounds and systems that have been duct taped to manage Medicare Advantage and Part D cause most of us the greatest headaches and compliance failures. There is no magic wand to resolve this—it takes diligence, documentation, and prioritization on a continual basis to raise up the next critical system needing to be resolved. Have your list of things needing to be fixed, the additional costs associated with the status quo, and the member impact ready and on the enhancement list.
- Provide Measurable Results of Success and Failure — Have a highly-visible way to measure individual and team success and failure. Successes should be celebrated. Share the successes and bring the feedback to your team. Failures should be evaluated—it isn't about the "who did it" but about the "why it happened." Everyone should be focused on mitigation. One of the items the audience discussed is ensuring you eliminate a culture of fear so staff is engaged in reporting non-compliance so it can be addressed. When non-compliance is identified, embrace it and thank those who raised the issue. Let them know how this positively impacted the department, company, and members.
- Manage Up — Sometimes we in management are the biggest barriers to compliant operations. We look at the production numbers and don't focus on the compliance measurements. We only give senior management what they ask for—it is our job to make sure the critical metrics and measurements go up to senior management. They often don't know the right questions to ask or measurements to review, and it is our job to bring this forward—it protects the company and our members.
We all have a part to play to ensure efficient, compliant operations are in place for our members. It takes 100% commitment to make sure the vision is carried forward. At Gorman Health Group, we know how important it is to link compliance and productivity. We are available to join with you to ensure that vision is firmly established in your organization. Please contact me directly at jbillman@ghgadvisors.com.
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