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.

Resources

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 >>


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.

 

Resources

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 >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>


Member Engagement — Are you listening to your members?

Member Engagement — Are you listening to your members? Do you understand what prospective members need and want from a health plan? Are you acting on the feedback you receive from your members? If you answered "no" to all or just one of these questions, your health plan may be missing opportunities to engage members and understand their needs.

Some of the most successful organizations are leaders when it comes to member engagement.  "When we look at companies with continuous long-term growth such as Nordstrom and Amazon, it is not attributed to just selling to new customers. It strongly based on keeping their current customers happy so they continue to purchase products from them. The Medicare Advantage industry should look at these companies as models for how their members should be treated," says Diane Hollie, Senior Director, Marketing and Sales Strategy at Gorman Health Group (GHG). This success is not by accident — these organizations spend a great deal of time developing ways to proactively gain and retain members. In the healthcare industry, we are now evaluated on how well we communicate, provide services, and overcome challenges. It's not enough to have a good benefit design — health plans must do much more to survive in this competitive marketplace.

In our quest to improve health plan performance, GHG has established tools to calculate the revenue impact of a single member. As you consider the value of investing in activities directed at the engagement and retention of members, it is helpful to understand the financial impact of member engagement. How much does a new member cost versus a retained, currently enrolled member?

Member communication, building trust, and consistent dialog throughout the member's journey plays a critical part in the success of member engagement. Each engagement method should be tested for effectiveness. Key member communication should include several components for the overall member experience:

  • Welcome Communication To build a positive first impression and begin the building blocks for member satisfaction and loyalty, new member outreach should include:
    • Welcome Call — Welcome new enrollees and create a positive first impression
      • Confirm they have received their ID card, plan materials, and understand benefits
      • Assist with any "immediate need" — coordination of care
      • Assistance with network considerations and primary care physician (PCP) changes
      • Invite new enrollee to an upcoming member meeting
        • Navigation through healthcare process
  • Education Communication — Member education helps ensure they understand benefits, features, and requirements for accessing their care. Confusion and frustration occurs when adequate information is not provided to the member and results in increased dissatisfaction. Providing members with accessible programs to help them navigate their benefits, available programs, and cost savings tips will help build loyalty. These programs should include:
    • Post Annual Notice of Changes meeting
    • Preventive care
    • Medication
    • Emergency
    • Low Income Subsidy
    • Identify socio-economic needs, financial support, transportation
    • Communication strategy for any service area reduction
    • Communication strategy for network changes affecting current patients
    • Care management
  • Engaging Communication — The cost of getting new members to enroll can be considerably greater than the cost of retaining current members, so placing emphasis on retention and loyalty throughout the year can make a meaningful difference and directly affect whether a member will stay with your plan. This program should include:
    • Loyalty programs, over-the-counter products, gift cards for yearly annual examination
    • Surveys: new members and those who have disenrolled
    • Monthly member events
      • Healthy cooking class, gardening tips, physician education, inspirational  speakers, health screenings
    • Reminders
      • PCP reminder call, flu shot reminder call
    • Thank you calls
    • Anniversary call/card
    • Birthday call/card

Careful design of proactive and reactive engagement initiatives and a commitment to communication will deliver a significant and positive impact on enrollment, member satisfaction, and revenue generation.

Now is the time to plan how to incorporate a member engagement strategy into your upcoming enrollment efforts, and GHG is here to help! Be the Amazon and Nordstrom in your marketplace!

 

Resources

Designed to meet a health plan's concerns for retention and service to the member while remaining compliant, Gorman Health Group's member experience assessment responds to the industry's demands by breaking down barriers that hinder the member experience. Visit our website to learn more about our Member Experience Services >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>


Teaming with Providers: Incentives to Achieve Results

When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs).

As health plans continue adapting to the growing influence of clinical quality on their provider network operations, building an effective team with your providers has never been more important.

But, factor in the necessities of compensating members of the team for their role, of each side meeting its profit targets, and the competing priorities faced by often short-staffed offices, it should come as no surprise many health plan staff members and providers are left wondering how to make it happen.

How do we as a health plan balance the range of providers in our network? How can we ensure the employed doctor with a large integrated delivery system has his/her needs met while at the same time engaging the single-office practitioner and ensuring his/her goals are met?

Meeting the needs for each of these scenarios and others starts with how well defined our provider incentive programs are. Do they adequately support the clinical and financial goals of the plan and the provider? Have we built an incentive program that has achievable and actionable benchmarks?

Whether your providers are still fee-for-service (FFS) or at full percentage of premium risk, a few building blocks will ensure success:

  1. Healthcare Is Local: Have we done our benchmarking for incentive programs at the local/regional level to ensure we are measuring apples to apples and taken into account the local practice of medicine?
  2. Prioritization: Ensure Clinical, Risk Adjustment, Star Ratings, Claims, and Network Operations are all collaborating and prioritizing their "asks" of the providers and working together to ensure the needs of the providers are met.
  3. Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
  4. Support ICD-10 Effective Implementation: If the Centers for Medicare & Medicaid Services (CMS) predictions hold true, denial rates and outstanding receivables are likely to increase during the conversion. Despite testing and readiness efforts, it's entirely possible some providers may not be staffed or prepared to mitigate technology-related problems among their payers or to weather the longer-term reduced productivity of their coding staff. Before your providers can invest additional energy into documentation for chronic conditions and quality priorities, they've got to keep the cash flowing
  5. Data Validation Reviews: Data integrity starts with collecting and configuring the provider data at the start of the contracting and credentialing process and becomes critical for downstream health plan operations. For example, the inclusion of an incentive program for achieving data accuracy, timeliness, and integrity is a critical element in your risk adjustment work plan. Offering incentives for providers to achieve and maintain 95% coding accuracy on all diagnoses, meaning 95% of the diagnoses submitted by the provider that can be substantiated in the medical record, subject to a random validation review, can often become a path to shifting providers to more risk-based contracting.  However, if your provider data is not correct or complete, the plan or its vendor can spend more time trying to find a provider than validate results.
  6. Focus on Actionability: Health plans often provide catalogs of reports each month showing providers numerous views of their panels and forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let the providers be providers.
  7. Continuous Measurement, Re-Evaluation and Reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a "thank you" are often simple but overlooked motivators.

In summary, there is no one straight line to navigate the path from FFS to pay for performance to risk for the plan or the provider, but there is one way to ensure success on that path —  collaboration between the plan and the providers. By breaking down the silos and barriers, being transparent in our actions, and reporting, we can build the trust needed to ensure we are not "checking the boxes" on the incentive plan but rather seeing the success in better patient outcomes and lower expenditures.

 

Resources

GHG's multidisciplinary team of experts will assess the alignment of your products, your current network and your market to 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 >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>


Retail Healthcare - An opportunity for success

Are you providing your members and potential members the opportunity to speak with you in person?

In the age of technology, we are forgetting how to serve our customers without them having to pick up the phone or log into a website. For some, this way of doing business fits the population they serve. It's fast and convenient, but in the Medicare world, we still have customers who want to speak with us in person, who need help navigating the complexity of healthcare, and sometimes it just can't be solved by pushing a button on a phone or computer.

So how do health plans continue to evolve in the technology world and still provide a personal touch while remaining profitable?

If providing quality healthcare and outstanding customer service is the objective of a health plan, and members and potential members want services on their time, in their neighborhood, then a brick and mortar location can solve for both.

Brick and mortar locations — or storefronts — can be used as a multi-purpose space for health plan staff, agents/brokers, and the surrounding community. These stores can be strategically designed for year-round activity or be used as a pop-up location during open enrollment and provide numerous advantages that online cannot:

Year-Round Opportunity:

  • Utilizing a variety of healthcare professionals such as medical groups and providers, senior associations, and ancillary community interaction at the store location.
  • Provide informational seminars for both educational and sales purposes, health and wellness information, engagement with the local community, age-in seminars, and Medicaid eligibility clinics to help the low-income population apply for Medicaid/Low Income Subsidy (LIS).

Seasonal Opportunity:

  • Facilitate sales seminars, lead agent appointments, walk-ins, and seasonal health fairs to drive Annual Election Period (AEP) awareness and educational seminars to bring awareness to the products and services offered by your health plan.

Achieving a measurable return on valuable marketing dollars goes a long way toward meeting growth objectives and improves profitability. With marketing budgets challenged by today's economic conditions, and the added pressure of Medicare Advantage rate reductions on health plan's cost structure and a shortened AEP, finding ways to maximize enrollment and spend less gets tougher and more challenging.

So whether your health plan is considering a year-round opportunity or seasonal location, this can bring your members and potential members a comfortable setting to gather, a place for the community to learn more about Medicare/Medicaid services, answer member questions, and troubleshoot issues pertaining to enrollment right in the heart of community — no dialing, no waiting — just fast and convenient.

Potential success with storefronts can be what your market needs, but careful design of a robust strategy is required to maximize your return on investment. Don't delay — Gorman Health Group can help you navigate the complexities and provide you with a plan that will surely satisfy your members, potential members, and your stakeholders.

 

Resources

At Gorman Health Group, we want to change the perception that member experience is the responsibility of Sales and Customer Service, instead showing organizations that member experience is a comprehensive approach with full transparency and cross-functional leadership. Visit our website to learn more >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>


Building A New Provider Network or Planning Your Next Service Area Expansion? Don't Lose Sight of Your Biggest Asset

The sun is shining, kids are out of school, and vacation season is in full swing! While our Health Plan Network and Product teams are taking a few deep breaths after application and bid filing deadlines, we cannot rest on our laurels for very long. Summer is the best time to start planning your next service area expansion (SAE) or even your first step into the Medicare Advantage (MA) world. Maybe you are an established MA plan evaluating where to expand your geographic footprint. Maybe you are a Medicaid plan looking to expand into the Managed Long Term Services and Supports (MLTSS) arena and are wondering what it would take to have a Dual Eligible Special Needs Plan so many of the MLTSS Requests for Proposal (RFPs) are expecting; or maybe you are an Accountable Care Organization looking to leverage your infrastructure and enter the payer world. Perhaps, maybe, summer is the perfect time to start planning for your network needs. Plans need to be even more vigilant in managing their largest asset. Regardless of the size and scope of the organization, your plan's network adequacy and accessibility is a cornerstone of any new initiative.

In today's marketplace, it is no longer acceptable to meet the bare minimum Health Services Delivery (HSD) requirement. Consumers, and the Centers for Medicare & Medicaid Services (CMS), are demanding plans be able to offer choices that include quality and cost efficiency. With consumer-savvy, newly-aged-in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their healthcare dollar. The new beneficiary is aging in from a world of patient engagement and incentive and reward programs and will expect the same level of service. Health plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals and be forward-thinking on how to best wrap risk adjustment and Star Ratings into the mix.

Additionally, the belt is tightening with day-to-day network management, and plans must reach out to their providers on a quarterly basis to confirm demographics and availability of their providers to ensure the information is updated in real-time with online directories and close the loop between the providers submitted on the HSD tables versus those in the directory. We will also delve into network adequacy and directory accuracy becoming part of the overall audit protocol pilot for 2016.

As we saw last year, many plans were unprepared to submit their entire network footprint in their SAE applications. The result was a scramble to fill gaps and re-evaluate if previously approved exceptions were, in fact, still valid. This requirement further supports the CMS commitment to monitor network adequacy for MA plans much more closely. It is time to set new network monitoring processes in place to ensure preparedness now.

At Gorman Health Group, we have a long history of providing the following:

  • Designing and developing a strong network strategy and provider engagement architecture that takes into account the quality, financial, risk adjustment, and Star Ratings goals needed for success within the competitive landscape of healthcare.
  • Direct contracting assistance to augment your staff to ensure contracting is done in an efficient and cost-effective manner.
  • The ability to do a deep-dive into a plan's provider files to ensure your specialty mapping meets CMS standards and definitions for each category.
  • Run multiple network adequacy and availability scenarios.
  • Prepare your plans' HSD tables for a CMS filing or prepare submission tables for a state or RFP filing.

Let us know how we can work and plan together now and build strategic network operations to support your plan's goals for growth. Summer planning will allow us to ease into fall knowing we are prepared for the new season!

 

Resources

Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to 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 >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>


Medicare Marketing Guidelines Summary of Changes — Have They Left You Scratching Your Head?

On June 10, 2016, the Centers for Medicare & Medicaid Services (CMS) announced the release of the 2017 Medicare Marketing Guidelines (MMG) for Medicare Advantage Organizations (MAOs) and Part D Sponsors.

Added language, clarification, and new requirements seem to be the theme with the recent updates.  So how do these changes affect business as we prepare for the 2017 Annual Election Period (AEP)?

At Gorman Health Group (GHG), our team of subject matter experts comes together to provide you with clarification around a few key changes from the final MMG Summary of Changes and recommendations for your organization.

Marketing — Diane Hollie, Senior Director of Sales & Marketing Services, says, "Although CMS has stipulated provider and pharmacy directories are considered non-marketing material, it doesn't mean the provider directories don't get submitted to CMS.  In fact, all plans must submit their hard copy provider directories to CMS on an annual basis."

CMS is now referring Sponsors to the Medicare Managed Care Manual, Chapter 4, for provider directory guidance and the Prescription Drug Benefit Manual, Chapter 5, for pharmacy directory guidance — making it a more complicated process.  The following are just a couple of provider directory rules found in Chapter 4, which were announced earlier this year in a 4/28/16 Health Plan Management System (HPMS) memo.

  • All hard copy directories must be uploaded into HPMS as a non-marketing material under the XXX submission code.
  • All hard copy directories must be uploaded prior to making the directory available by September 30.
  • Because provider directories are considered non-marketing, MAOs should not include a status after the material ID.
  • To distinguish the provider directories as non-marketing, the following material ID should be used:  plan's contract number, followed by an underscore, followed by a series of alpha numeric characters chosen at the discretion of the plan, followed by an underscore, followed by the letters "NM."  Example:  HXXXX_ABC124_NM

While it is noted the MMG has referred readers to the PDBM, Chapter 5, for pharmacy directory guidance, there is no cross-referenced information.  This could be an indicator a revised Part D Chapter 5 will soon be released. Without it, Sponsors will be left scratching their heads.

SalesCarrie Barker-Settles, Director of Sales and Marketing Services, understands the importance of agent/broker oversight and Sponsor sales activities.  "Helping plans/Part D Sponsors and agent distribution channels navigate the dos and don'ts of the rules and regulations can be very overwhelming, but at GHG, we can make that challenging task less daunting for both."

Below are just some of the changes relating to sales oversight:

  • Telephonic Contact — Plans/Part D Sponsors may call their current MA and non-MA enrollees or use third parties to contact their current MA and non-MA enrollees about MA/Part D plans.  Examples of allowed contacts include calls to enrollees aging into Medicare from commercial products offered by the same organization and calls to an organization's existing Medicaid/Medicare-Medicaid Plan (MMP) enrollees to talk about Medicare products. The updated guidance clarifies, when discussing Medicaid products, Sponsors must follow all applicable Medicaid marketing rules. Plans/Part D Sponsors, sellers, and telemarketers may conduct these telephonic activities, but we recommend you fully understand all the regulations for both unsolicited and solicited contact before reaching out to Medicare beneficiaries.
  • Compensation Payment Requirements — Whether you use employed, captive, and/or independent agents, you must inform CMS yearly by the end of July which channels you will be using as well as the compensation payment rates or ranges.  The compensation structure must include:
    • How the Plan/Part D Sponsor intends to disseminate compensation, specifying payment amounts for initial and renewal compensation.
      • CMS has clarified in the revised guidance the compensation structure must stay the same for the compensation year that was put in place by October 1.

Some Plan Sponsors may have already been following this process, but if not, yearly requirements outlined in the MMG suggests all Plan Sponsors check policies and procedures to ensure they adhere to their clarification.

"I come from a trust but verify world," says Regan Pennypacker, Senior Vice President of Compliance Solutions," and when the updated MMG is released, it's important Compliance teams disseminate the document to ensure affected business units can determine impact."  "It's also important," she states, "to reconcile and ensure supplemental memos and clarification emails sent between revisions have also been rolled into the new guidance."  For example, the Part C aspects of the August 13, 2015, "Clarification of CY2016 Medicare Marketing Guidelines" has indeed been rolled into the MMCM, Chapter 4, but as noted above, the Part D aspects pertaining to pharmacy directories has not. "This means plans will need to continue to reference that memo to ensure they are following the guidance as it pertains to pharmacy directories."

"Overall," states Regan, "it will be important for Compliance to partner with Sales and Marketing staff to ensure adherence to all changes and clarifications."

We have highlighted just a few of the key changes, but to learn more, register to join our upcoming webinar on June 28, 2016, from 1 - 2 pm ET.

Resources

Once you have your PBPs in place (we can help with that, too), our teams can develop or review your sales collateral and creative by product type to help ensure your high-impact messaging is both targeted and compliant. Visit our website to learn more >>

Gorman Health Group's Sales Sentinel™ is a flexible, module-based software solution with the ability to onboard agents, provide training, manage ongoing oversight activities and pay commissions.  Created by GHG, Sales Sentinel™ was designed to address the specific needs of government managed care organizations. Request a demo today >>


AEP Marketing and Sales Readiness — Do You Pass the Quiz?

The following are questions Gorman Health Group would ask when conducting an assessment on marketing and sales strategies and execution plans for our Medicare Advantage clients.  Take the quiz today and see if you are on track for a successful Annual Election Period (AEP).

If you have answered "no" to any of these questions and you feel you are behind the eight ball — contact us, and we can get you on the right track. AEP is just around the corner!


Resources

Understanding what's working and what's not within your sales and marketing plan is a must in the ever changing competitive Medicare market.Our seasoned veterans will work with your team to redefine sales and marketing strategies that will pay big dividends short and long-term at your plan. Visit our website to learn more >>

Gorman Health Group's Sales Sentinel™ is a flexible, module-based software solution with the ability to onboard agents, provide training, manage ongoing oversight activities and pay commissions.  Created by GHG, Sales Sentinel™ was designed to address the specific needs of government managed care organizations. Contact us today to set up a demo >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>


How do health plans increase brand recognition and improve brand loyalty?

It is believed brands who engage on social media channels enjoy higher loyalty from their consumers.  So why should health plans and health professionals engage in social media?

Social media provides a key opportunity for health plans and health professionals to build relationships with Medicare beneficiaries through social media, develop trust, and collaborate to design future programs to support the needs of the ever-changing Medicare population.

Social media creates an environment where consumers feel comfortable sharing honest feedback and feel a sense of community.  Health plans can use this environment to communicate health and wellness tips, upcoming community events, and, as we enter into the Annual Election Period (AEP), these channels can help promote new products and services, help position products for growth, and provide a place to tell a story about your organization and the services you provide.

Are you still asking yourself if social media make sense for your particular audience, or is it a big waste of marketing dollars?  Here are a few additional reasons why social media can help drive engagement, satisfaction, and promotion:

Health Plan

  • Social media is not just a marketing tool — it is now a business and communication strategy
  • Provides innovative ways to communicate with both prospects and members and deliver key messages about your products and services in real time
  • Ability to use current members as advocates to share their positive experiences with your health plan
  • Influence consumers not easily reached though traditional or direct communication channels

Consumer

  • Consumers now play an active role in their healthcare, obtaining real-time data from their doctor and their health plan through their smartphone or tablet
  • Allows consumers additional outlets to receive information in the way they feel most comfortable
  • Capture the young adults helping their aging parents gain information and help navigate the complexity of our healthcare system

Is your 2017 social media plan in place?  Don't miss out on the opportunity to engage consumers with a communication tool to proactively engage, educate, and identify negativity outcomes with current and future members.

 

 Resources

Gorman Health Group an unparalleled track record working with clients in government programs to develop cost-effective strategies and tactics to help plans achieve maximum potential for their products. Visit our website to learn more >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>


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.

 

Resources

We've assisted scores of organizations through every step of the application process, from gathering the right data, completing the application, submitting, and responding to follow-up questions. Don't let the application process get in the way of your day-to-day operations.  Contact us today to ensure a smooth, compliant process >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>