RISE WEST 2021 10 lessons learned
CAHPS® SURVEY RESULTS How to leverage them for maximum impact
COMMUNITY PARTNER NEWS See P. 18
nº7 - Fall 2021
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QUALITY & REVENUE COMMUNITY NEWSLETTER
Letter From the Chair
HOW TO LEVERAGE YOUR ® RECENTLY RELEASED CAHPS SURVEY RESULTS FOR MAXIMUM IMPACT Over the past few newsletters, I’ve leveraged this space to urge plans to take action to improve the Patient Experience Measures (comprised of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) (except flu), disenrollment, appeals, call center, and complaint measures) that will be more heavily weighted in the 2023 Medicare Part C & D Star Ratings. Given recent action by the Centers for Medicare & Medicaid Services (CMS) to move two 3x-weighted HOS measures to Display for 2022 and 2023, that urgency has become an existential imperative for many plans, as the patient experience measures (and CAHPS in particular) eat up an even greater slice of the Star Ratings pie.
Your CAHPS Scores are in … now what? Earlier this month, Medicare Advantage (MA) plans received their 2021 CAHPS survey results. Instead of simply
sharing the results throughout your organization and promising to do better next year, seize this moment to dive deep into your data to uncover actionable insights, identify opportunities to improve your member experience and precisely target where to direct your resources (people, time, and investment) for the rest of this coverage year and into Q1 of next year. Each measure could be approached from a variety of different directions, so it’s important to figure out which aspects of the member experience need improvement and, of those, which ones your plan is actually capable of tackling. TIP: Begin by evolving the way you think about your CAHPS survey results, from viewing them as a discreet set of stand-alone data to scrutinizing the results in combination with other forms of member feedback.
Evaluate your plan’s results against one or more benchmarks Not all benchmarks are created equal. Choose benchmarks with your plan’s long-term strategy and improvement goals in mind. Here are some good sources of comparative benchmarks* to consider: • CAHPS Health Plan Survey Database contains results for the Medicaid survey submitted by various sponsors, including public employers, State Medicaid agencies, State Children’s Health Insurance Programs (CHIP), and individual health plans, as well as Medicare Survey results provided by CMS. To access this data, visit https://datatools.ahrq.gov/cahps • NCQA’s Quality Compass® presents quality improvement and benchmark plan performance through online access to health plan HEDIS® and CAHPS performance data. Plans can create custom reports for up CLICK TO SEE OTHER ARTICLES
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to three trended years, comparing measures and benchmarks (averages and percentiles). To access this data visit, https://store.ncqa.org/data-andreports.html • C omparative Data from CMS’ Health Plan Survey includes scores calculated from responses to the MA and fee-for-service (FFS) survey versions and reports state means using both the original survey scale and the 0-100 scale. This source also includes detailed current and historic response rate information for MA and PDP CAHPS, and overall rates for MA, PDP, and FFS CAHPS. To access this data visit, https://www.ma-pdpcahps.org/en/ comparative-data/ • Your survey vendor: Most vendors will provide comparative data for their book of business.
* Keep in mind that in 2020, CMS did not collect Medicare CAHPS data due to the COVID-19 pandemic and therefore, results for 2020 are not presented in many of the above data sources.
Understanding the various ways to analyze your data There’s a myriad of ways to dissect your CAHPS results that make use of benchmarks as reference points from which to view your plan’s performance.
Your Score
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Measure
The key is choosing the methods that are the most applicable with the understanding that not all comparative data will be relevant to your unique organization. For example, comparing your plan’s performance to regional or national averages may not be as meaningful as comparing yourself to the average scores for similar organizations. And, if you need to make significant leaps, comparing yourself to the top performers (looking at top box scores) may be a more effective way to set the bar than comparing yourself to the averages. • C omparing averages: Compare your plan’s mean scores for composite and rating measures with the average mean score for other plans (nationally or by state). See what trends you can identify. Check out which individual measures are dragging down your composite scores and how your performance compares to that of other plans. • Comparing top box scores: The percent of respondents that chose the best possible response option (i.e., yes, definitely or always) is referred to as a “top box” score. You can compare your plan’s top box score with that of other plans, again paying close attention to composite measures and the individual measures that make up the composite.
• C omparing percentile scores: The distribution of scores across all health plans included in a benchmark are referred to as percentile scores. For this calculation, scores for all participating plans are ranked from low to high. The percentile (i.e., 90th percentile, 25th percentile) indicates the percentage of organizations that scored at or below a particular survey score. To understand where your score falls, find the highest percentile where your score is higher than the percentile score. In the example below, the plan’s score in the composite measure “Getting Needed Care” is 61, which is higher than the score for the 75th percentile. That means the plan scored higher than the 75 percent of plans in this measure. The plan’s score for “Easy to get necessary care, tests or treatment” was 68, better than 90 percent of plans. However, the plan’s score for “Got appointment with specialist as soon as needed” is 56, better than only 50 percentof plans, suggesting that this particular measure is driving down the composite measure score. Doing this type of analysis allows you to more precisely pinpoint where to find opportunities for improvement. (See chart below) • Comparing yo u r c u r re n t performance to past performance:
Lowest Score
10th
25th
50th
75th
90th
Highest Score
61
Composite: Getting Needed Care
36%
46%
50%
55%
59%
62%
69%
68
Easy to get necessary care, tests, or treatment
36%
49%
54%
58%
62%
67%
73%
56
Got appointment with specialists as soon as needed
30%
43%
48%
53%
57%
60%
65%
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When available, comparing your most recent performance to your past performance can be a useful tool to determine whether interventions are working or whether you need to make changes to your strategy or tactics. Use this type of analysis to find trends in top box scores as well as comparing your mean scores. • Figuring out what’s most important to your members: Understanding what issues are important to your members will help you tactically choose the areas to focus on for improvement. This type of analysis, referred to as “key driver” analysis, entails examining the correlation between a particular individual question or composite measure and the member’s overall rating of the health plan. The stronger the association, the higher the importance.
Prioritizing measures to work on Once you understand your performance and what’s important to your members, you can create a priority list of measures by placing measures of low performance and high member importance higher on the list. It might be helpful to create a visual representation by organizing all Star Rating CAHPS®measures within a priority matrix such as the one below. LOW PRIORITY HIGH PRIORITY MEASURES MEASURES
Measures where plan had high performance, but were of low importance to members
Measures where plan had high performance, but were of high importance to members
MEDIUM TOP PRIORITY PRIORITY MEASURES MEASURES
Measures where plan had low performance, but were of low importance to members
Measures where plan had low performance, but were of high importance to members
Putting it all together Once you’ve prioritized the measures you want to improve upon, it’s time to figure out what actions you can take. Get curious about what qualitative info you can use to better inform what you’re seeing in the quantitative data. For example, if you notice that the measure “Got Appointment with specialists as soon as needed” is dragging down your “Getting Needed Care” composite measure, look at other sources of information, such as your call logs, grievance and appeals data, and provider accessibility studies to see if the issue is popping up in any of those places as well. What are members and providers saying? Are you seeing grievances related to this issue? How about appeals related to requests for out-of-network coverage? Then, brainstorm potential reasons why members may be having trouble getting appointments when they need them. If the answers aren’t immediately obvious, dive deeper to get at the inherent causes of performance issues by trying one or more of these proven methods for problem solving: • • • • •
Root cause analysis Process mapping Process observation Walkthroughs Small-scale surveys
The results of the above efforts should help you understand what you can fix right away and what will take more time and effort. That awareness should shape your strategy for approaching the specific measures you want to tackle with improvement activities.
As always, if you’re charged with championing these measures at your health plan, I remind you to not feel daunted by the work ahead. Each of the steps above takes a concerted effort and time, but none of it is rocket science. Get started as soon as possible, and in the words of Franklin D. Roosevelt, “above all, try something.” Take the first step and get help if you need it. 2023 Stars is around the corner. Designing your CAHPS improvement strategy is too important to wait another day.
Your investment of time, money, and resources in these critical Star Ratings measures, if leveraged smartly, will pay off in spades.
Ana Handshuh, CHC, Principal, CAT5 Strategies, RISE Quality & Revenue Community Chair
Finally, zero in on what specific improvement activities you will ultimately focus your time, money, and energy on by considering the prevalence of the issue you’re hoping to correct, how far away your score is from others (how big is the opportunity for improvement), your existing improvement projects, and where these improvement activities fit within the framework of other plan strategies, priorities, and initiatives.
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OIG audit targets Aetna MA program; Medicare continues to make overpayments for chronic care management services; and more
Most ACA insurers don’t expect COVID-19 to impact 2022 costs; CMS issues OPPS proposed rule; and more
CMS inpatient rule repeals MA rate disclosure requirement; Premium for Medicare Part D projected to increase 5% in 2022; and more
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QUALITY & REVENUE COMMUNITY NEWSLETTER
10 LESSONS LEARNED FROM RISE WEST 2021 Jim Loehr, Ed.D,, opened the conference with an inspiring keynote.
Our 2021 hybrid event was jam-packed with content, including three keynotes, a panel where we heard directly from Medicare Advantage members, and panels that offered insights into legal issues, member engagement, and payer-provider collaboration. Four hundred attendees safely gathered in-person at The Broadmoor in Colorado Springs, while 200 others participated in the event via their home offices. In her opening remarks, Ana Handshuh, CHC, principal, CAT5 Strategies, and chair of RISE’s Quality & Revenue Community, urged attendees
to make the most of the networking and learning opportunities at the conference. “This has been a challenging yet very exciting time for all of us in the health care industry. People are reprioritizing their expectations, not only us, but our enrollees, our patients. They are taking a look at what is important to them,” she said, noting that she has a sense from talking to attendees at the conference that they are aiming to innovate to better serve their members and do something that is greater than themselves. If you didn’t join us, here are 10 takeaways from the event:
1. OUR HEALTH IS THE BACKBONE TO OUR ACCOMPLISHMENTS World-renowned performance psychologist Jim Loehr, Ed.D., co-founder of Johnson & Johnson Human Performance Institute, delivered an inspiring and introspective keynote address this morning where he offered takeaways from his 30-plus years of applied research and training of elite performers from diverse arenas, including Olympic gold medalists, military Special Forces, hostage rescue teams, surgeons, and Fortune 500 CEOs to achieve sustained high performance. CLICK TO SEE OTHER ARTICLES
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He’s worked with some of the greatest talent and brightest minds, but the pillar to performance always came back to health for Dr. Loehr. “We can’t do much if we don’t have health,” he said. It was one of many life-lessons he would gain through his work. Throughout the thought-provoking presentation, Dr. Loehr shared the biggest career insights he realized over the years. Among them: Our health ignites our performance. To become a performer in any area of our life–whether it’s at work, in school, or as a mother or father–we must be healthy physically, emotionally, mentally, and spiritually, according to Dr. Loehr. Purpose is the centerpiece of everyone’s life. When you understand your true purpose, everything else falls into place. And the more your purpose is “self-transcending” and has less to do with you and more about those around you, something magical happens, he said. “You open that vault, and you dig deeper than you ever would have done had it been for your own self-preservation or needs.” There’s a hidden scorecard in life. Have you ever thought about the legacy you wish to leave behind? Or what you hope to be remembered for? That’s our hidden scorecard, and it’s a great indication of where to put our emphasis
and energy in present time, explained Dr. Loehr. Who we are as persons is far more important than who we are as performers. The person you’re becoming along the chase as a performer is more important on the priority list than the performance itself, said Dr. Loehr. “There is what you achieved, and there is how you got there. What price are you paying to get to the top of the mountain?” Energy investment spawns life. It’s not the time you invest in something that makes the difference but your energy. Stress exposure is the stimulus for all growth, and recovery is when growth occurs. Stress isn’t the bad guy in life, said Dr. Loehr, rather the insufficient recovery from stress physically, emotionally, mentally, and spiritually is the true culprit. Our story is our destiny. We can change our story and our destiny at any time, noted Dr. Loehr. But first, you must unearth the story that failed to get the job done to gain a new mindset, commitment, sense of purpose, and understanding. Full engagement is our greatest gift to the world. We breathe life into wherever we invest our energy, so be intentional about where you wish to have an impact and step into that space with full engagement, said Dr. Loehr.
Our inner voice is the most important coach we will ever have in our lives. It’s important to speak to ourselves the way we would speak to someone we dearly care about, for our private voice is the “master storyteller” of our life, noted Dr. Loehr. Mental toughness is not just mental. It’s physical, emotional, mental, and spiritual, and you have to work each area, advised Dr. Loehr.
2. EXPECT THE BIDEN ADMINISTRATION AND THE DEMOCRATIC-CONTROLLED HOUSE AND SENATE TO GET SEVERAL HEALTH-RELATED PRIORITIES PASSED UNDER BUDGET RECONCILIATION During a panel discussion on the Biden Administration’s Impact on Managed Care, Marc Goldwein, senior vice president and senior policy director, Committee for a Responsible Federal Budget, provided an overview on the Democrats’ proposed spending plan and the administration’s overall policy for health care. Among the priorities: the response to COVID-19 including boosting vaccinations and stopping the spread of the virus; expanding insurance and benefits; and lowering health care costs. How much of those goals will be addressed in the proposed $3.5 trillion
Below: Industry roundtable: from far left, Sean Creighton, Mikal Sutton, David Meyer, and Michael S. Adelberg. Marc Goldwein joined virtually.
Above: Mikal Sutton answers a question during the panel discussion. 8
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spending plan remains to be seen, but Goldwein said that lawmakers are discussing extending one-time expansion of Affordable Care Act subsidies, closing Medicaid coverage gaps, extending long-term care benefits, expanding Medicare by dropping the eligibility age to 60, and expanding benefits for the elderly and disabled, including adding a dental, vision, and hearing component to Medicare; and allowing Medicare to negotiate drug prices for public and private plans. There is also some talk of provider payment reform, especially among those who believe Medicare Advantage plans are overpaid. “The last issue,” he said, “is the solvency of the Medicare Trust Fund.” Yesterday the Medicare Trustee board issued a new report that the Medicare’s insurance trust fund that pays hospital will run out in 2026. This issue will loom large over the next four to five years he said. Goldwein said that in the short-term the administration is focused on the budget reconciliation package and will fast track the opportunity to pass the $3.5 trillion legislation, which will only need 50 votes to pass. But that package will include spending on education, climate change, child care, tax credits, as well as health care. “Policy makers are having three fights. How are we going to spend, how are we going to divvy up that spending between health care and non-healthcare, and within healthcare, where are we going to divvy it up,” he said. Although some lawmakers are hoping to get the budget passed next month, Goldwein predicted it will likely take place in two or three months.
the challenges they faced with COVID-19, member engagement, provider burnout, and the strategies they used to mitigate them. One of the biggest challenges: Forecasting and making assumptions last year without any historical data. This year plans will have to see how their assumptions played out, said Elaine Taverna, senior vice president risk adjustment and quality, Advantasure. “You couldn’t even retrospectively look back at what happened and make assumptions on a national basis. It was different region by region. The COVID experience was unique, which meant you had to have a good ability to track and monitor what was happening.” Early on in the pandemic, Rick Liu, vice president, risk adjustment, SCAN Health Plan, said he saw provider visit rates dropped 50 percent within his network. “We knew we had to do something and figure out how long that would be, how many waves we were going to have, a lot of guesswork. And now we are trying to figure out how close that was,” he said. CDPHP® launched a campaign for patients and providers called “Don’t Delay Care” that they promoted on all available channels, explained Renée Golderman, senior vice president, chief quality officer. The campaign focused on encouraging members to not be afraid to seek care and to call their provider to discuss the safest options including visits by telephone, telehealth, and if necessary, in-person. Some providers even saw patients in parking lots, she said. As important as membership engagement was and ensuring that members received the care they needed, panelists said they also focused on the needs of their networks of providers.
3. PATIENT CARE, MEMBER ENGAGEMENT, AND PROVIDER SUPPORT CONTINUE TO BE FOCUS AREAS FOR HEALTH PLANS AS THE PANDEMIC CONTINUES
“We are all hearing what our health workers are going through the last two years,” Taverna said. “We are hearing of an exodus nationally of the labor force because of what they have gone through, and they don’t want to go through it again.”
During a discussion on the current and future state of risk adjustment and Star ratings, panelists opened up about
One way to connect with your providers, Golderman said, is partnering with
them on key quality metrics and capturing conditions. “Doctors want good clinical outcomes for their patients,” she said, noting that her plan collaborated with providers to obtain the best outcomes for patients and structuring a capitated risk agreement. “Our physician network embraced that,” she said. Liu said SCAN Health didn’t aggressively pursue chronic condition management, HCCs, and risk adjustment in the early months of the pandemic so providers could focus on patient care. “We had to understand there were priorities that the providers groups had to do. We knew there would be tradeoffs we were going to have to deal with and project out, but one thing we started to do was back off. We really needed the country to deal with the pandemic first and foremost and give providers the space to handle that. We continued programs, but tried not to be as aggressive,” he said. “It was really recognition and letting the doctors deal with the situation at hand.” The panel said this year’s focus areas will include new members and provider encounters, utilization data to better understand unrecognized chronic conditions needs, expansion of in-home assessment programs and telehealth, support of primary care providers and wrap-around programs, seek out opportunities for risk-adjustable chronic condition capture, and get access to EMR data to ramp up for retrospective coding.
4. ALIGNED EFFICIENCY EFFORTS FORGE PROVIDER/ PAYER COLLABORATION During the provider engagement track, providers shared their transparent perspectives on the keys to provider/ payer collaboration in a post-pandemic world. Throughout the session, panelists engaged in open dialogue around what’s working well within their organizations, the practices they find effective in reducing barriers, and the pain points they still run into while collaborating with payers. While examining the stand-out activities that contribute to their organizations’ success, the panel shared an inside look at their unique approaches. Some of the CLICK TO SEE OTHER ARTICLES
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most effective activities shared included a senior health services program led by a team of advanced practice providers to help facilitate coding gaps, quality gaps, and assist in the completion of annual wellness visits; a digital care center that encompasses a centralized call center as well as a clinical contact center to provide remote patient monitoring, outreach to schedule visits, and documentation for annual wellness; and incentive programs for support staff to provide quality patient care as well as comprehensive office performance. When it comes to providers being increasingly asked to carry out administrative work related to risk adjustment and quality value-based care in general, the panelists shared a couple tactics that they have found successful, such as the roll-out of online appointment scheduling, PA patient calls to complete all pre-visit documentation for annual visits, the utilization of best practice advisory alerts through an EMR, and provider coaches in select care settings to not only provide care but serve as educators. The panel also highlighted the importance in providing an educational platform to physicians in areas including accurate coding, coding opportunities, and standardized documentation. Education for the support staff is just as important, noted panel speaker Jennifer Ross, director of risk adjustment, compliance programs, Aegis Medical Group. “Having your support staff understand the business model—and unfortunately in health care, now it is a business model—the business model that you have is extremely important,” said Ross, noting Aegis Medical Group has also implemented an incentive program for support staff that has been extremely successful in enhancing office performance.
5. TELEHEALTH IS HERE TO STAY AND MAY REINVENT HEALTH CARE AS WE KNOW IT COVID-19 forced health care organizations to quickly adapt and take advantage of telemedicine platforms to continue to care for patients. But will the 10
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The virtual panel discussion on telehealth: Clockwise from top left,: Mark Ishimatsu,. Laura Sheriff, Andy Ellner, and Mark Bigelow. industry continue to embrace the technology post-pandemic? Yes, and it may completely change the way we practice medicine, according to panelists who discussed the current successes and future of telehealth. The discussion, led by Moderator Mark Bigelow, vice president, EXL, explored the challenges health payers faced when pivoting to telehealth, the successes they had reaching Medicare populations, and strategies for training physicians on how to properly use the platform and document the care provided for billing purposes. Among the panel’s suggestions: Segment populations most likely to benefit from telehealth visits: Risk Adjustment Specialist and Consultant Laura Sheriff said during the initial shift to telehealth she focused on scheduling follow-up visits for members who were recently discharged from the hospital. The other population she focused on was behavioral health patients, who in many instances felt more comfortable meeting practitioners from their homes. Create “telehealth cheat sheets” for providers: Sheriff said she created these training sheets to help providers learn how to properly bill for services and make sure they noted in their documentation that they conducted a telehealth visit with audio and visual components. Collect more member data for demographic profiles: Mark Ishimatsu, director of enterprise risk adjustment,
L.A. Care, said the plan widened its targeting efforts during the pandemic because of a drop in general in-person encounters. Part of those efforts are using in-person home assessments to collect elements for demographic profiles to determine how they want to connect with providers and what type of technologies they are comfortable using. Take advantage of the platform’s ability to ease access to care: COVID revealed the inequities of access to care, Ishimatsu said. The introduction of newer technologies opens opportunities to think about different models of care delivery. Expect telehealth to reinvent traditional primary care: Andy Ellner, M.D., founder, Firefly Health, a virtual primary care practice established in 2016, said he expects more primary care practices may move away from in-person visits to a virtual platform like the one Firefly built. He believes many people, particularly the Medicare and Medicare Advantage population, have difficulty coming to a clinic to meet with providers in person and there are technology-enabled applications they can use for better care management.
6. HOW TO REMOVE THE BARRIERS TO CHANGE AND BREAK THE STATUS QUO BIAS We heard a compelling keynote address from International Bestselling Author and Professor Dr. Jonah Berger. As a world-renowned expert on change,
word of mouth, influence, consumer behavior, and how products, ideas, and behaviors catch on, Dr. Berger shared actionable steps to change anyone’s mind and how to apply the techniques to be more forward thinking in the managed care space and improve payer, provider, and member relationships. Change is hard for people, he said. But it is possible to get people to change their minds without providing them with more facts and figures. Because people have a “status quo bias”—the tendency to stick with what they know and do already because it’s familiar and safe—it’s important to think like a chemist and find a catalyst to lower the barrier to change. People need to feel like they are in control and might make the change if they feel as if they came to the decision on their own. To help give them this freedom and control, Dr. Berger suggests you: Provide a menu of options: Don’t give people one option. Give them a guided choice of limited choices like a menu at a restaurant. By providing options, it gives people the feeling they are in control, and they won’t focus on the choices not before them. Ask, don’t tell: Too often we state what we want to happen, but people don’t like to do as they are told. Instead, ask them what they think. By asking questions, rather than making a statement, it allows people to arrive at the right answer and makes them feel like they are participating in the solution. If they came up with the solution in the first place, it
makes it difficult for them to resist the change. Highlight a gap in attitudes and actions: People typically want their attitudes and actions to line up. For example, if they say they care about the environment, they will recycle. But sometimes they are inconsistent, and you can show how their attitudes and actions don’t match. “Too often we think something is an information problem,” Dr. Berger said. “It’s rarely as much an information problem as we think.” Allow people to experience the benefits before they incur costs: We usually ask people to pay for something upfront before they know for sure that a product or service will make their lives better. There are always some costs to change but the benefits are uncertain. Uncertainty is great for the status quo, but not good for change, he said. Instead, lower the barriers to the product or service by offering “freemiums” or a trial to try the product or service before they upgrade to the premium option. It’s like renting before buying. Dr. Berger left the audience with two key takeaways that can be implemented
immediately: Find your “parking brakes,” or the obstacles and barriers getting in the way of change, and then determine how to mitigate them. “We have to understand the problem and the barriers before we prescribe a solution.”
7. WHAT MA MEMBERS LIKE, DISLIKE ABOUT THEIR HEALTH PLANS One of the most popular sessions each year at RISE West is a focus panel moderated by Kathleen Ellmore, managing director of Engagys, and made up of Medicare Advantage (MA) members who discuss their policy choices, their overall health plan experiences, access to care, and what plans can do to improve services. This year’s panel of 10 MA members didn’t disappoint and were candid about their likes and dislikes, including the reasons for switching plans, whether they pay attention to Star ratings, and why they would or wouldn’t opt for a telehealth visit in the future. This year’s panel of 10 MA members didn’t disappoint and were candid about their likes and dislikes, including the reasons for switching plans, whether they pay attention to Star ratings, and why they would or wouldn’t opt for a telehealth visit in the future.
Keynote Dr. Jonah Berger on how to change anyone’s mind. CLICK TO SEE OTHER ARTICLES
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Reasons why they switch or would consider switching plans: Primary care physician no longer included in the provider network; increase in premiums and copays; and difficulty obtaining referrals to specialists. The most important factors when considering a new health plan: Easy access to high-quality primary care physician and referred specialists; coverage of procedures and medications; cost (premiums and copayments); and supplemental
benefits (such as gym memberships and vision coverage for contact lenses and prescription eyeglasses). How they find out about different health plans: Most said they receive paper flyers in the mail and then look at the individual health plans on their web sites to compare coverage and costs. Whether Star ratings factored into their decision of enrolling in a plan: Only two panelists were familiar with Stars. Of the two, one senior said he did consider Star ratings as well as word of mouth when he chose his plan. The other said the rating was not a determining factor when she enrolled in her plan. 12
QUALITY & REVENUE COMMUNITY NEWSLETTER
However, when Ellmore explained the Star rating system, most of the panelists said they would look for 1-5 quality rating the next time they considered switching plans. Their thoughts on the level of communication from their health plans: Responses were mixed. Five felt their plan offered just the right level of communication, three said they didn’t get enough, and two thought they received too much information. One senior said
he got too many explanation-of-benefits forms that came months after his doctor visits, so it was difficult to reconcile whether he actually received the service. But another said he wished he got the explanation of benefits more frequently. Two members said they prefer getting statements via mail so they can write notes on them for future reference; others preferred digital and say they can print statements if they need a hard copy. Whether they feel as if their plans know them as individuals: Only two felt their plans really knew them. One senior said the health plan follows up with him to see if he made it to his scheduled appointments, including visits to his
urologist and podiatrist. The plan also sends him a printout of his conditions and what he needs to address with the physicians. “It makes me feel good and gives me a sense they know me,” he said. Among those who didn’t feel as if their plan knew them: Ways that health plans could personalize communications is to reach out about preventive care services available to them and send information about how to follow a healthier lifestyle. What they think about telehealth visits: Half of the panel said they participated in a telehealth visit during the pandemic. Two didn’t like the experience; one said it was superficial and he missed the hands-on aspect of in-person visits; the other scheduled three separate appointments and each time was kept in a waiting room for hours and the doctor failed to show up. Other panelists had more positive experiences. They liked the option because they lived far away from their providers. One woman said she made an appointment after hours and the doctor was very responsive, even checking in on her in the waiting room to let her know how long it would be until he could meet with her. How plans could improve the overall member experience: Provide information (even in an email) about how close they are to reaching the donut hole and suggest inexpensive alternatives to purchasing medication once they reach it; offer online chat capabilities on their websites so they can get an immediate response to their questions or
Kathleen Ellmore, managing director of Engagys, moderates a conversation with Medicare Advantage members.
concerns rather than waiting for a return phone call days later; cut the cost of premiums; allow seniors to use their entire discretionary account amount for overthe-counter products at once, rather than divvying up the amount quarterly (“I could buy a better blood pressure monitor with $160 at the beginning of the year, rather than a cheaper version with the $40 quarterly allowance”); offer members a specific name and contact information of a benefit specialist who they could reach out to with questions; and provide extra incentives to encourage preventive care, such as gym memberships.
8. AN INTEGRATIVE, CROSSFUNCTIONAL APPROACH IS KEY TO EFFECTIVE MEMBER ACQUISITION, OUTREACH, AND RETENTION During the member engagement and experience track this afternoon, co-panelists Scott Weiner, director, government programs, Virginia Premier, and Archie Dey, director of consumer experience and insights, SCAN Health, spoke about the strategies they’ve found to drive results in member acquisition, outreach, and retention. A fundamental approach to their strategies: Cross-functional coordination across departments to align initiatives and member communications. Both Weiner and Dey agreed coordination between teams is critical to ensure members aren’t inundated with communications. SCAN Health has been a 4.5-Star plan for the last four years. A cross-functionality type of intervention that SCAN uses is the plan’s coordination of care program for prescriptions. To provide a seamless member transition during the onboarding process and prevent lapses in prescriptions, the plan collects data on members’ prescriptions and identifies any that don’t fall within the SCAN formulary. SCAN then coordinates with the provider group to make sure the member has at least one month of the prescription and then begins the prior authorization process. The health plan also works with members to ensure they understand the
Virtual panel on member engagement and experience: Clockwise from top far left: Moderator Steve Wigginton, Scott Weiner, and Archie Dey. different prescription options available for them. “It’s a coordination between the sales team, enrollment team, customer service team, health care service team,” said Dey. “What we do is run a cross-functional initiative where the stakeholders from the different teams come together, and we come up with a process flow which identifies what each team has to do as part of the entire workflow.” Both Weiner and Dey discussed how their plans are leveraging cross-functional coordination in their efforts to address social determinants of health (SDoH) and promote health equity. The plans’ strategies include a new case management system to identify the ZIP code areas likely to experience social needs, a peer-to-peer program between older adult volunteer members and members in need of connection, and a vaccination program for homebound members. While showing ROI and business case around SDoH and health equity can be a challenge, they remain a priority for the plans. “Think small, prove the value in it, and then build on top of it because I don’t always believe attribution is the right question to solve for,” explained Dey. “My perspective is you need to look at the entirety of the interventions where the whole is bigger than the sum of its parts.”
9. LEGAL INSIGHTS ON MA RISK ADJUSTMENT,
FALSE CLAIMS ACT CASES, COMPLIANCE ISSUES Our compliance & audit readiness track featured a blockbuster panel of legal experts who offered insight into the current state of the law in Medicare Advantage risk adjustment and discussed the difference between “garden-variety breaches of contract or regulatory violations,” which are not actionable under the False Claims Act (FCA), and compliance failures that constitute actual fraud. Among the takeaways: The government is intervening in a high percentage of risk adjustment qui tam complaints, said Edward Baker, counsel in Constantine Cannon’s District of Columbia’s office. He noted that the government has intervened or participated in 15 of the 22 whistleblower cases filed – an astronomical number. Those cases with government involvement have either settled or are still pending. The result of those cases is a clear theme: You can’t seek payment for diagnoses that aren’t supported in the medical record. More and more investigations focus on reverse false claims, says Jonathan A Porter, who serves as assistant United States attorney in the Savannah, Ga. Office of the United States Attorney’s Office for the Southern District of Georgia. These types of claims involve claims submitted in the past, but later someone in the organization determines it was CLICK TO SEE OTHER ARTICLES
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improper. In that case, the organization has an obligation to go back to someone within the government and make it right. Materiality–or whether the defendant knowingly violated a requirement that is known to be material to the government’s payment decision–is crucial in these cases. The key is determining the line between “garden variety” or a mere regulatory violation or whether the case crosses over to fraud. Even “garden variety regulatory violations” can become a billion-dollar problem, warned Stephen Bittinger, health care audit & integrity partner, K&L Gates, LLP. His advice is to stay current and be aware of what the law says. While it’s impossible to keep track of every single process, he suggests that organizations look at processes quarterly so they can catch problems and correct anything in a timely manner. “The big problem is if your internal set of data is different than what you submitted to the government,” he said, adding that organizations should have well-defined policies and protocols for discovering errors and correcting errors quickly. Follow available guidance and adapt your practices to limit risk, said William
Sarraille, senior partner, health care group in the District of Columbia office of Sidley Austin LLP. Guidance is limited and it’s difficult because so many fundamental issues are not addressed, he said. His advice is for organizations to follow risk adjustment data validation audits and enforcement developments to best understand lessons on what went wrong. Changes may be coming to the False Claims Act, says Porter. The origins of the federal law date back to the Civil War when contractors provided fraudulent goods to the Union Army. Porter said he’s heard that Sen. Chuck Grassley (R-Iowa) and others are interested in tweaking the False Claims Act to update it so it can be better applied to the complex issues the industry faces today. “I think we will see something like that in the years to come as courts continue to figure out what the delineation is between garden variety and knowing false claims,” he said.
10. How To Invest In Businesses That Serve The Most Vulnerable Populations The conference concluded with an impressive keynote by Andrey
Ostrovsky, M.D., managing partner, Social Innovation Ventures, and the former chief medical officer for the U.S. Medicaid Program. Dr. Ostrovsky, a pediatrician, shed light on where money can be made in the health care space and where that money will do good, particularly investments that serve vulnerable populations and innovations that address the social determinants of health. He encourages making investments into businesses that can show evidence behind their solutions (evidence that supports their marketing claims), those businesses who have diverse leaders and who offer a unique perspective to innovation, and those that will ensure the solution will get in the hands of patients. He provided several examples of these types of innovations, including a business that uses virtual reality to treat chronic pain, a nonpharmacological way to manage ADHD, and artificial intelligence that can diagnose autism (a diagnostic tool designed to be anti-racist and unlike human beings, doesn’t discriminate based on race, ethnicity, socioeconomic status, or geographic area). He said he is also broadening his
Above: RISE West celebrates a successful event with an event-wide selfie. 14
QUALITY & REVENUE COMMUNITY NEWSLETTER
Top and at right: Closing keynote Andrey Ostrovsky, M.D. investments to include affordable housing and artistic endeavors. By making an investment in these types of businesses and showing that his fund can outperform the consensus internal rate of return, Dr. Ostrovsky said he hopes institutional investors will increase their funding of innovation for vulnerable populations. So far, the results have been promising: • Since 2018, he has invested in 26 companies • Fifteen of those companies had diverse founders (not white, nonheteronormative, and/or non-male) • Twelve raised first institutional round since his investment • The internal rate of return net fees was 41 percent (exceeding his goal of 30 percent) • Return on equity has been 301 percent
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Dr. Angela Huskey on emerging drug threats, the rise in substance use among the elderly
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UPCOMING EVENTS Transitioning From Retrospective to Prospective Chart Reviews for Early Risk Identification
SEE WEBINAR DETAILS
Tuesday, September 28th at 1:30 pm EST
HCC Coding User Group #2 (Meeting 4) Tuesday, October 12th at 1:30 pm EST
RISE HEDIS® & Quality Improvement Summit October 24-26, 2021 Loews Coronado Bay, Coronado, CA
The 18th Risk Adjustment Forum November 15 - 17, 2021 Caesars Palace, Las Vegas
The 12th Annual RISE Star Ratings Master Class December 14-15, 2021 Manchester Grand Hyatt, San Diego, CA
Women in Health Care Leadership Summit December 14 - 15, 2021 Manchester Grand Hyatt Hotel, San Diego, CA
RISE National 2022 March 7-9, 2022 Gaylord Opryland, Nashville
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COMMUNITY PARTNER NEWS Executive insights on the evolution and future of digital transformation: What payers need to know CIOX
How AI, NLP technologies automate risk adjustment processes GeBBS Healthcare Solutions, Inc. 7 considerations when choosing the best health care BPO partner
Reimagining member engagement Change Healthcare
Shearwater Health
Vaccine schedule adherence promotes better health outcomes Inovalon
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