The Secret to Success World-renowned performance psychologist Dr. Jim Loehr to share all at RISE West 2021
RISE National 2021 Recap: Keynotes wow with presentations on COVID-19, digital innovation, and health care mega-trends
Innovation Care Partners’ Dr. Heather O’Toole named this year’s Martin L. Block Award winner
How to achieve true member centricity with a grassroots approach
Nº6 - Summer 2021
THE LATEST NEWS 2022 Payment Notice: CMS issues second notice that includes risk adjustment changes for ACA marketplace
House bill would expand telehealth coverage to include audio-only for MA members
CMS panel, international strategic forecaster to headline the 17th Risk Adjustment Forum
News notes: CMS extends special enrollment period, releases snapshot on COVID-19; Murthy to serve as US surgeon general for a second time
Feds give huge funding boost to Navigator program for ACA enrollment
BMA study: Medicare Advantage saves members $1,640 a year
Humana health plan overcharged Medicare by nearly $200M, federal audit finds
Health care leaders welcome Becerra’s confirmation as HHS secretary
Research roundup: AEP switchers take advantage of OEP; MA beats Medicare in quality, outcomes, and costs; and more
Senate confirms Chiquita Brooks-LaSure as CMS administrator
CMS chief medical officer, customer experience expert to present keynotes at Qualipalooza 2021–a RISE hybrid event
The 2021 ‘State of Medicare Advantage’: 7 findings from BMA’s annual report
READ OUR ENTIRE COLLECTION OF INSIGHTS AND ARTICLES
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QUALITY & REVENUE COMMUNITY NEWSLETTER
Letter From the Chair
ARE YOU READY FOR THE
2021 PROGRAM
INTEGRITY
AUDIT? Jennifer Dupee, director of the Centers for Medicare & Medicaid Services (CMS) Center for Program Integrity Audits and Vulnerabilities Group recently announced that the organization has initiated Program Integrity (PI) Audits for Medicare Advantage and Prescription Drug Plans for calendar year 2021. The Center for Program Integrity’s mission is to detect and combat fraud, waste, and abuse (FWA) of the Medicare and Medicaid programs. CMS is performing these audits in collaboration with the Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC). The May 17 announcement stated the purpose of the PI Audits is to evaluate plans’ efforts to prevent, detect, and correct FWA. The PI Audits will focus on practices employed by plans to address program integrity risks and FWA as part of plans’ standard operations.
The following areas are included in the scope of the PI Audits: • Identification and prioritization of FWA risks • FWA monitoring and auditing • Effective compliance with statutory and regulatory requirements, guidance, and direction • FWA complaints, investigations, referrals, and requests for information (RFIs) • Proactive FWA initiatives Can you demonstrate the following parts of your compliance program are working effectively? CMS discusses Compliance Program Guidelines in detail in the Medicare Managed Care Manual Chapter 21 and Prescription Drug Benefit Manual Chapter 9. Before CMS comes knocking, look at the guidelines and assess whether you can demonstrate your program’s effectiveness in the following areas that specifically address FWA: CLICK TO SEE OTHER ARTICLES
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Compliance officer, senior management, compliance committee, and governing body Do you have the right oversight structure in place? Make sure that your plan’s compliance officer has appropriate authority to prevent, detect, and correct potential FWA, including overseeing the implementation of corrective action plans as well as coordinating potential fraud investigations with internal and external parties. You should also be able to demonstrate that senior management, the compliance committee, and the governing body are involved in overseeing the effectiveness of the compliance program to reduce the risks of noncompliance and FWA. Code of conduct and compliance policies and procedures Make sure your code of conduct describes your plan’s expectations that issues of noncompliance and potential FWA are reported through appropriate mechanisms; and that reported issues will be addressed and corrected. Your FWA policies and procedures should be detailed, specific, and address issues such as the plan’s compliance reporting structure, compliance, and FWA training requirements; the operation of the hotline or other reporting mechanisms; and how suspected, detected, or reported compliance and potential FWA issues are investigated, addressed, and remediated. Make sure you can demonstrate that your plan distributed the code of conduct and policies and procedures s to all applicable individuals within the timeframes required by CMS. FWA training Make sure your staff and governing body members receive FWA training within 90 days of hiring and annually thereafter. Topics that should be addressed in FWA training include but are not limited to: laws and regulations related to Medicare Advantage and Part D FWA (i.e., False Claims Act, Anti-Kickback statute, HIPAA/HITECH, etc.); having appropriate FWA policies and procedures; processes to report suspected FWA and protections for those who do; and types of FWA that can occur in the settings in which employees work. CMS suggests that additional, specialized, or refresher training may be provided on issues posing FWA risks based on the individual’s job function and in special circumstances. Make sure you’re able to demonstrate that all applicable individuals have fulfilled the training requirements as applicable. Examples of proof of training may include copies of sign-in sheets, employee attestations, and 4
QUALITY & REVENUE COMMUNITY NEWSLETTER
electronic certifications from the employees taking and completing the training. Plans are accountable for maintaining records for a period of 10 years of the time, attendance, topic, certificates of completion (if applicable), and test scores. And, although CMS no longer requires First Tier, Downstream, and Related Entities FDRs) to complete its Combating Medicare Parts C and D Fraud, Waste, and Abuse Training, plans are still responsible for FDR compliance. Therefore, make sure your FDRs complete some version of FWA training that applies to the delegated functions and that they can demonstrate they’ve done so. Mechanisms to report FWA Plans must have a system in place to receive, record, respond to, and track compliance questions or reports of suspected or detected noncompliance or potential FWA. The reporting mechanisms should be user friendly, easy to access and navigate, and available 24 hours a day for employees, members of the governing body, and FDRs. You should also educate your members about identification and reporting of potential FWA. Make sure you can demonstrate that your reporting systems can maintain confidentiality (to the greatest extent possible) and allow anonymity if desired. Finally, you should be able to demonstrate that you widely publicize and enforce a no-tolerance policy for retaliation or retribution against anyone who in good faith reports suspected FWA. Identifying and responding to risks If you haven’t done so yet, you should establish a formal baseline assessment of your plan’s major compliance and FWA risk areas (i.e., a risk assessment). Your assessment must consider all operational areas. Risks identified must be ranked to determine which risk areas will have the greatest impact, and you must prioritize your monitoring and auditing strategy accordingly. Because risks change and evolve with changes in the law, regulations, CMS requirements, and operational matters you should review your risks on an ongoing basis (at least annually). Risk areas identified through CMS audits and oversight, as well as through your plan’s own monitoring, audits and investigations are priority risks. The results of the risk assessment should inform the development of the monitoring and audit work plan. Monitoring and auditing You should develop a monitoring and auditing workplan that includes addressing FWA. Your work plan should
reflect your size, organization, risks, and resources to assess performance in areas identified as being at risk. Be sure that your workplan incudes a comprehensive strategy to monitor and audit your FDRs. Finally, ensure you can demonstrate that you’ve addressed your identified risks within your auditing and monitoring workplan and that you’ve conducted any appropriate follow up for corrective actions. OIG/GSA exclusion Make sure you can demonstrate that you reviewed the OIG and the General Services Administration (GSA) exclusion lists prior to the hiring or contracting of any new employee, temporary employee, volunteer, consultant, governing body member, or FDR, and monthly thereafter, to ensure that none of these persons or entities are excluded or become excluded from participation in federal programs. It’s imperative that you maintain these records so that you can access them during audit situations. Proactive activities Data analysis can be used proactively to prevent and detect FWA, which should include the comparison of claim information against other data to identify unusual patterns suggesting potential errors and/or potential fraud and abuse. Many plans invest in data analysis software applications that give them the ability to analyze large amounts of data to detect FWA both internally and externally. Whether you use software or other simpler mechanisms, be sure to document these processes and any ensuing activities thoroughly so that you can demonstrate your proactive efforts for preventing and detecting FWA. Special investigations unit (SIU) If your plan does not currently have an SIU that’s separate from the compliance department, you must ensure that responsibilities generally conducted by an SIU (i.e., conducting surveillance and interviews; identifying members with overutilization issues; identifying and recommending providers for exclusion and referring cases of illegal drug activity to the MEDIC and/or law enforcement; and assisting law enforcement by providing information needed to develop successful prosecutions) are conducted by the compliance department. Be sure to document these activities.
Prompt response to identified issues Make sure your plan has documented processes for promptly responding to issues as they are raised, investigating potential FWA problems identified by self-evaluations and audits, correcting problems promptly and thoroughly to reduce the potential for recurrence, and ensuring ongoing compliance with CMS requirements. This means conducting timely and reasonable inquiry into any evidence of misconduct related to payment or service delivery; conducting appropriate corrective actions; and having procedures to voluntarily self-report potential FWA to CMS or other appropriate entity, such as the MEDIC. In Chapters 21/9, CMS outlines the process for referrals to the MEDIC. Make sure you have procedures in place to handle such referrals and to document the actions you took. CMS also expects plans to take appropriate action related to CMS-issued Fraud Alerts, which describe schemes identified by law enforcement officials. Finally, make sure you can demonstrate that you maintain files on both in-network and out-of-network providers who have been the subject of complaints, investigations, violations, and prosecutions as required by CMS. Looking at the state of your program with a critical eye to ensure your FWA program components are effective will help you put your best foot forward if your plan is selected for the PI audit. Consider seeking help if you need additional bandwidth to conduct your assessment. Or, at minimum, divide up the work within your own department, and complete a simple checklist outlining what you could demonstrate today and where you may have gaps. CMS stated that plans selected for the audit will receive additional communication regarding the audit and next steps. Plans with questions about the audit may send an inquiry to CPIMedicarePartD_Data@cms.hhs.gov with “Program Integrity Audit 2021” in the subject line.
Ana Handshuh, CHC Principal, CAT5 Strategies RISE Quality & Revenue Community Chair
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RISE National 2021 Recap: Keynotes wow with presentations on COVID-19, digital innovation, and health care mega-trends It was an amazing three days of RISE National 2021, featuring timely updates for 2021 and 2022, insightful keynote addresses, and collaborative panel discussions. If you missed it, we’ve gathered the highlights for you.
5 POWERHOUSE KEYNOTES Olympic Gold Medalist Tara Lipinski was the first keynote to take the virtual stage, during an inspirational preconference event open to all attendees. Now a figure skating analyst for NBC Sports Group, when she was 15-years-old Lipinski became the youngest-ever gold medalist in her sport during the Olympic Winter Games in Nagano, Japan in February 1998. She describes her Olympic moment as a surreal experience when everything she worked for came together for four minutes and she skated her best program. “It was the happiest I ever felt,” Lipinski said. “I felt an overwhelming sense of relief, joy, and love for skating. Asked what parents can do to help their children face high pressure competitive situations, Lipinski said it’s important to have a support system but also truly love the activity. “I loved to skate so much, it balanced out the pressure I was under…You have to love it enough that it cancels out the other areas that are really difficult so make sure your kid is sort of in love with the sport. That will help and motivate them.” In addition to her love of ice skating, one technique that is especially helpful even to this day is visualization, Lipinski said. A sports psychologist suggested she tape herself talking through her ice-skating program, including how it felt when she landed a move, and she’d fall asleep listening to the tape. The psychologist said that it would get into her subconscious and body. “It really worked on the tricks your mind plays and how to overcome those doubts,” she said. During the main conference, we heard from health care policy expert Ezekiel J. Emanuel, M.D., who discussed the current progress on COVID-19 vaccines and predicted a 6
QUALITY & REVENUE COMMUNITY NEWSLETTER
sense of normalcy, given no distribution disruptions, by the end of the third quarter or into the early fourth quarter of 2021. Beyond COVID, Dr. Emanuel discussed potential areas for reform, such as primary care capitation, mental health care, and electronic health records and the creation of a patient smart card that could allow for real-time data monitoring of conditions and medical visits. Infectious disease expert Dr. Luciana Borio blew us away with her candid assessment on COVID-19, the United States’ response, the vaccine distribution timeline, and the impact of the pandemic on health care. In a conversation with RISE National Conference Chair Ana Handshuh, Dr. Borio said the United States didn’t respond adequately in the early months of the virus, as indicated by the millions of cases in the United States and the death toll, which currently is at 549,000. She said that one of the country’s biggest failures was the denial about the virus and the promotion of unfounded treatments and ideas to achieve herd immunity. However, she gives the United States high marks for our vaccine program. Although we will see improvements and life slowly returning to normal over the course of the next year, Dr. Borio advised Americans to continue to wear masks, practice social distancing, and avoid indoor dining and indoor socialization with strangers. Meanwhile, she advices health care professionals to watch for mental health and isolation issues that are emerging, particularly among seniors who fear leaving their homes, and for conditions that may exacerbate because so many Americans deferred care in the last year. Wendy Sue Swanson, M.D., pediatrician & author, Mama Doc Medicine, spoke about how digital innovations can enhance the patient experience. Dr. Swanson discussed how the new tech landscape offers outstanding, innovative
opportunities for efficient, yet humanistic, exchange of information in healthcare. The key she said, is to create a dual-centric system that meets the needs of both the patient and the provider. In her highly inspirational talk, Dr. Swanson talked about the lessons from outside our industry that we can leverage within our industry. She challenged us to not sit on the sidelines, but rather to think outside the box and fully engage with our members and patients in completely new and innovative ways. Health care futurist Ian Morrison offered insights on the future of the health care marketplace. Morrison discussed implications of health care policy based on the new Biden administration, the continued impact of COVID-19, and mega-trends such as artificial intelligence, data analytics, and the intersection of social determinants of health and digitalization. Morrison emphasized the way in which “the game” of finances in health care is played in America, with costs continually increasing and certain services are more expensive than ever before. While there’s been substantial disruptions in the health care industry, Morrison sees huge opportunities for digital innovations, such as consumer applications to enhance the patient and member experience, chronic care and behavioral health applications, post-acute care transitions, population health initiatives, operations 2.0 core systems, and a rise of virtual care capabilities and competitors.
REGULATORY UPDATES Representatives from the Centers for Medicare & Medicaid Services (CMS) offered updates on both risk adjustment (RA) for the Affordable Care Act market and RA updates for Medicare Advantage and Part D program. They reviewed the Proposed Model Specification Changes in the 2022 Payment Notice, 2021 RA model changes, and the RADV Final Rule. They also discussed operations updates on 2019 and 2020 RADV and EDGE LDS, policies in the 2022 Rate Announcement, and offered an overview on the CMS-HCC model 2022 risk score calculation. The RISE Risk Adjustment Policy Committee discussed today’s political climate and its impact on health care. The recently passed American Rescue Plan Act of 2021 was focused primarily on COVID-19 relief and getting the economy on track. Any significant Medicare provisions will take place in a second reconciliation bill, they said. Two areas to watch: potential payment cuts to Medicare Advantage and a proposal to expand original Medicare to cover dental, hearing, and vision. Updating original Medicare with the supplemental benefits currently offered by Medicare Advantage plans is both an opportunity and
a threat. Medicare Advantage plans would have an opportunity to build on the benefits they already offer, but the rate of growth the industry has seen in recent years may not continue if original Medicare becomes more attractive to members. Frank Micciche, vice president, public policy and external relations, National Committee for Quality Assurance (NCQA), provided an update during a fireside chat with Conference Chair Ana Handshuh. He explained that the organization will now reference HEDIS® by the measurement year or the year in which care is delivered, and proposed changes aimed to help close the gap on health equity. In addition, NCQA is working to close the gap on health equity and has proposed changes that would encourage organizations to focus on identifying whether there are disparities within their populations and if so, to make sure they are able to document and update what they are doing to address disparities. “Quality care is equitable care,” Micchiche said, noting you can’t have high-quality care if there are segments of your community that are underserved. During an update from the Office of the Inspector General, representatives provided a look at the vulnerabilities in Medicare, particularly due to telehealth services during the COVID-19 public health emergency. The OIG has found risks within cost-sharing waivers for telehealth services, telehealth services that did not meet Medicare requirements, and kickback, medically unnecessary services/ items. They also went over the findings from recent OIG risk adjustment audits for Essence Healthcare, Inc. and Blue Cross Blue Shield of Michigan, which revealed that some of the diagnosis codes submitted for use in the Centers for Medicare & Medicaid Services’ risk adjustment program didn’t comply with federal requirements. Diagnosis codes submitted either weren’t supported in the medical records or couldn’t be supported because the medical records couldn’t be located.
KEY TAKEAWAY Conference chair Ana Handshuh and RISE Risk Adjustment Policy Member David Meyer wrapped up the conference by reflecting on the amazing presentations over the three days, the strong presence of government and regulatory officials from CMS, OIG and NCQA, and the running theme of the impact of COVID-19 on the health care industry and the need for a phased-in return to normal. One big takeaway, they said, is that the pandemic has shown that broadband access and connectivity should be considered a social determinant of health. CLICK TO SEE OTHER ARTICLES
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World-renowned performance psychologist Dr. Jim Loehr to share the most important factor in achievement, life satisfaction at RISE West 2021 Join RISE for a special presentation with Jim Loehr, Ed.D., co-founder of Johnson & Johnson Human Performance Institute, who will offer insights into his 30-plus years of propriety research and training of elite performers, including Olympic gold medalists, military Special Forces, hostage rescue teams, surgeons, and Fortune 500 CEOs to achieve sustained high performance. RISE is pleased to announce that Dr. Jim Loehr will be a keynote speaker at RISE West 2021, a hybrid event that will take place August 30-September 2, live in Colorado Springs and virtually via livestream for those unable to travel. 8
QUALITY & REVENUE COMMUNITY NEWSLETTER
His presentation, Lead with your best foot forward–lessons learned from the world’s best athletes to achieve sustained high performance, will focus on the single most important factor in successful achievement, personal fulfilment, and life satisfaction, with takeaways on how you too can learn these characteristics. His keynote will take place at 11 a.m. EST, Wednesday, Sept. 1. Dr. Jim Loehr is a co-founder of the Human Performance Institute, a world-renowned performance psychologist, and author of 17 books including his most recent, Leading with Character. He also co-authored the national bestseller, The Power of Full Engagement. Dr. Loehr’s ground-breaking, science-based energy management training system has achieved world-wide recognition and has been chronicled in leading national publications, including the Harvard Business Review, Business Week, Fortune, Newsweek, Time, U.S. News &
World Report, Success, Fast Company, and Omni. He has appeared on NBC’s Today Show, ABC’s Nightline, The CBS Evening News, The CBS Morning News, and the Oprah Winfrey Show. From his more than 35 years of experience and applied research, Dr. Loehr believes the single most important factor in successful achievement, personal fulfillment, and life satisfaction is the strength of one’s character. He strongly contends that character strength can be built in the same way that muscle strength is built through energy investment. Dr. Loehr has worked with hundreds of world-class performers from the arenas of sport, business, medicine, and law enforcement, including Fortune 100 executives, FBI Hostage Rescue Teams, and military Special Forces. A sampling of his elite clients from the world of sport includes golfers Mark O’Meara, Justin Rose, and Daniel Berger; tennis players Jim Courier, Monica Seles, and Arantxa Sanchez-Vicario; boxer Ray Mancini; hockey players Eric Lindros and Mike Richter; and Olympic gold medal speed skater Dan Jansen. Dr. Loehr has been inducted into two Hall of Fames, was a pioneer in the application of psychology to human performance, has received numerous sport science and coaching awards, and has lectured world-wide on his performance technology. He is currently applying his insights regarding character to youth.
He possesses a masters and doctorate in psychology and is a full member of the American Psychological Association. The Human Performance Institute’s training is the result of decades of proprietary research and working with elite performers. The Institute’s training draws on the sciences of performance psychology, exercise physiology and nutrition to create lifelong behavior change. By training to expand and manage energy levels both personally and professionally, performers ignite their full potential in high stress arenas. RISE West is the premier Medicare Advantage senior leadership conference, bringing together experts in risk adjustment, quality performance, documentation, and HCC coding practices. This year’s event will feature three tracks, virtual and in-person workshop options, and sessions focused on policy, regulatory, and legislative updates, the current and future state of Star ratings, risk adjustment revenue management and reaction to deferred care as a result of COVID-19, and strategies for audit-readiness, member acquisition, engagement, and retention, and provider engagement and education. RISE West 2021 will take place August 30-September 2, live in-person at The Broadmoor, Colorado Springs, and virtually via livestream. For more information, including the preliminary agenda, list of speakers, and how to register, click here.
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DR. MARTIN L.
BLOCK AWARD RISE exclusive: Innovation Care Partners’ Dr. Heather O’Toole named this year’s Martin L. Block Award winner
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QUALITY & REVENUE COMMUNITY NEWSLETTER
Heather O’Toole, M.D., chief medical officer at Innovation Care Partners, a clinically integrated network and an accountable care organization in Arizona, received RISE’s highest quality award at this year’s RISE National. Dr. O’Toole, who has been instrumental in improving palliative care through educating primary care physicians, as well as training care coordinators and transitional care managers on advance directives, was chosen out of a field of 11 nominees for this year’s award. The Martin L. Block Award for Clinical Excellence and Innovation is presented each year to an individual who has advanced the lives of America’s seniors through clinical leadership, policy vision, and by superior example of the RISE mission to promote continuous improvement in the health care system. The award is given each year at RISE National in honor of the late Dr. Martin L. Block who passed away in October 2013 of brain cancer at the age of 62. Dr. Block was a regular speaker at RISE National and an expert in the risk adjustment industry. After narrowing the field of candidates to three finalists, the award committee selected Dr. O’Toole for the 2021 Block Award due to her long-standing dedication to excellence with her leadership spanning a broad range of colleagues, including practicing physicians, care coordinators, and analysts. Dr. O’Toole was nominated by Priya Radhakrishnan, M.D., vice president, chief academic officer, social determinants of health, and health equity at HonorHealth, a clinically integrated system in Scottsdale, Ariz. She described Dr. O’Toole as making a significant impact on the care of seniors and in the health care industry through the development of an ambulatory opioid bundle for safer prescribing and management of chronic opioid patients within the outpatient setting. Additionally, she has made significant contributions through her work in the transitional care management services for Medicare and Medicare Advantage patients. A career devoted to population health, quality improvement Her list of achievements is extensive. The nomination describes Dr. O’Toole as instrumental in working alongside HonorHealth to improve palliative care. She serves on the Palliative Care Steering Committee and Advance Care Planning (ACP) subcommittee, she has revised ACP documents, and she advised on an ACP template for appropriate documentation in the electronic health record (EHR). She also educated more than 300 primary
care providers in the ACO on the importance of advance care planning discussions and trained more than 50 care coordinators and transitional care managers on advance directives and ACP discussions. Dr. O’Toole is a member of the Arizona Medical Association End of Life Care Task Force and the Arizona Coalition to Transform Advanced Care. Along with a team of colleagues from HonorHealth, Dr. O’Toole developed an ambulatory opioid bundle for safer prescribing and management of chronic opioid patients within the outpatient setting. She worked on an EHR workflow that prompts for a prescription drug monitoring program review before a provider prescribes medication, as well as a prompt that alerts inpatient and outpatient providers to whether a patient has a Controlled Substances Agreement on file. Within Innovation Care Partners, she developed an opioid dashboard with data from its valuebased agreements, including Medicare and Medicare Advantage plans, that identified chronic opioid patients, as well as those at higher risk, and the proportion of patients with a filled Narcan prescription and urine drug screen completed within the last year. In addition, the dashboard provided lists of high-risk patients who were prescribed greater than 50 morphine milligram equivalents without Narcan and the dangerous combinations of an opioid and benzodiazepine or opioid and Soma prescribed within a 30-day period. She was part of the core team that was recognized by the AAMC Opioid Stewardship award in 2019 that showed significant (more than 50 percent) improvement in the opioid bundle. She also has made significant contributions in the transitional care management services for Medicare and Medicare Advantage patients discharged from acute care hospitals and post-acute facilities. She worked with Innovation Care Partners’ clinical team of care coordinators as part of a pilot program to use the organization’s developed census to reach out to patients within two business days of discharge. The census template featured requirement elements, such as medication reconciliation. During the pilot program at a few key primary care practices, the care coordinators called in daily with their status on outreach to patients and reviewed any barriers. Dr. O’Toole intervened in several situations to alleviate barriers, such as scheduling issues, and developed an educational handout to help capture all the needed components from primary care providers and care coordinators. After roll-out of the transitional care management process, she continued to train more than 50 care coordinators annually and fielded questions as needed. By implementing this process, the organization has averted unnecessary emergency department visits and readmissions and improved patient satisfaction. CLICK TO SEE OTHER ARTICLES
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In 2018 and 2019, Dr. O’Toole was the ambulatory champion for quality and performance in both the HonorHealth Medical group and Innovation Care Partners and successfully transitioned the medical group’s quality leadership to another physician but continued to serve as a presence on the organization’s Quality & Safety Committee to ensure that its quality initiatives were aligned across the organizations. She participated in the weekly ambulatory champions EHR meeting that prioritized clinical decision support tools and dashboards to educate and promote improvements in quality. Most of her quality initiatives are in the Medicare Advantage and the Medicare Shared Savings Program space. Every quarter she has face-to-face (now video due to the pandemic) visits with primary care providers in which they review quality initiatives, educate on measures, and provide feedback.
Kumar Dharmarajan, M.D., chief scientific officer, Clover Health, who has worked for 15 years as a clinician, health services researcher, quality improvement expert, and leaders of health care delivery and payer organizations. Dr. Dharmarajan has generated pivotal data and leveraged it through systems building and improvement to enhance health care for America’s seniors. Sharon Jhawar, PharmD, MBA, MCGP, chief pharmacy officer, SCAN Health Plan, who has improved the ability of seniors to access quality health care. A geriatric pharmacist by training, Dr. Jhawar has led at a population level for close to two decades. Other nominees included:
Dr. O’Toole also developed a quality improvement project in 2019 for primary care practices to choose measures from a narrow set of choices that align with Innovation Care Partners’ quality focus, such as depression screening, colorectal and breast cancer screening, opioid measures, and annual wellness visits. The practices are asked to develop an action plan with suggestions provided, and then the team at Innovation Care Partners provides baseline performance and quarterly snapshots. With successful completion of the quality improvement project, the organization submit to the American Board of Family Medicine for credit for performance improvement activities for board certification.
• Mary Agens, BSN, RN, CPM, executive nursing director for clinical informatics, Florida Department of Health
Dr. O’Toole said she is honored to be the recipient of the award and accepted it on behalf of her colleagues who helped with the various initiatives that improved the outcomes and health of the organization’s seniors.
• Jan Lee, M.D., chief executive officer, Delaware Health Information Network
“My career started as an Airforce family physician and that’s where my interest in population health was really sparked,” she said. “Over the years I’ve transitioned from primary care to chief medical officer at Innovation Care Partners. We’ve piloted many different initiatives to really think out of the box to drive outcomes for our populations and it’s been truly exciting to see how health care has been transformed these last few years and will continue to change. We look forward to other projects and looking to analytics and other technologies like artificial intelligence, to drive outcomes.” An impressive field of nominees This year’s field of candidates for the award was particularly competitive. Individuals were nominated for their significant impact on the care of seniors and for years of exemplary work in the health care industry.
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The two other finalists were:
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• Cyndi Alexander, chief adherence officer, AdhereHealth, LLC • Joy Bland, vice president of quality, Magellan Complete Care • Joseph Cardinalli, PharmD, pharmacy manager, Contra Costa Health Plan • Ximena Galarza-Rios, M.D., physician, Lovelace Medical Group
• Aditi Vyas, M.D., population health medical director, Riverside Healthcare • Patrick Yost, M.D., physician, Memorial Hospital of Converse County Previous winners RISE has presented the Block Award since 2014 when it was given posthumously to Dr. Martin Block. Past winners also include: • James M. Taylor, 2015 • John Broderick, 2016 • Michelle Lupoli, R.N., 2017 • Manjusri Vennamaneni, 2018 • Mark Dambro, 2019 In 2020, amid the COVID-19 pandemic, RISE chose to forego the traditional criteria of the award and instead, presented it in honor of the health care professionals who contracted and died from COVID-19.
How to achieve true member centricity with a grassroots approach Here’s how three organizations targeted social determinants of health (SDoH) and accomplished improved health outcomes beyond the clinical walls.
During a live-streamed conference session led by Signify Health at the RISE National 2021 virtual summit in March 2021, panelists shared the innovative solutions their organizations have implemented in their respective markets to achieve true member centricity.
Kronkosky Charitable Foundation’s Alamo Area Community Network (AACN) Cara Magrane, director of initiatives and partnerships, Kronkosky Charitable Foundation, shared the initiatives of AANC, a community referral platform, to bring together community-based organizations (CBOs), payers, providers, and funders in the Signify Health platform to impact the wellbeing and health of the San Antonio community. AACN goes far beyond just an electronic referral platform, said Magrane. The community network strives to cultivate a deeper level of collaboration between nonprofits and funders to ensure CBOs and nonprofits, who have long addressed SDoH, have a voice at the table due to their critical work that has a fiscal impact on the community and health systems.
“Often, we’re very well intentioned as stakeholders, whether we are funders, or community-based organizations, or payers, and we really want to impact the SDoH realm of our world, however, in order to do so there’s a lot of silos to be broken down, there’s intense levels of communication and transparency that need to happen,” said Magrane. In addition to increasing collaboration, AACN aims to identify patterns in client needs, capture SDoH, reduce duplication of efforts, identify gaps in services for unmet needs, and gather cross-sector evidence. The community network also seeks further funding for community organizations. While organizations are currently funded through grants, the money is not robust enough to impact bigger system change, causing CBOs to remain dependent on funders, state systems, and local systems, she explained. To provide another source of income for organizations solving for SDoH, AACN aims to implement and impact Centers for Medicare & Medicaid Services (CMS) billing codes to ensure resources funnel down to CBOs. While AACN just launched in September 2020, it could not have come at a better time amid the COVID-19 pandemic. As part of the San Antonio’s community recovery resiliency plan, the city was mandated to create an electronic platform for CBOs to connect people to services, which AACN was promptly able to provide, allowing the city to amplify and onboard an additional 50 organizations. CLICK TO SEE OTHER ARTICLES
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Humana’s Bold Goal To double down on its commitment to improve the health of its members, Humana launched its Bold Goal strategy in a handful of selected markets, starting with the San Antonio community, which led to a collaborative partnership with the AACN and Signify, explained Jackie Rivera, population health strategy lead, Humana. The goal: To improve the health of the communities Humana serves 20 percent by making it easier for people to achieve their best health. “We’ve learned the significance of looking at social and economic factors and what impact those have on a person’s health. So, if 60 to 80 percent of what makes a person healthy is impacted by nonclinical factors, we have to look at the whole picture,” she said, noting the priority to focus on the integration of clinical and social care in the same ecosystem became very obvious. “Humana realized and recognized it wasn’t enough to just support community work as they address social health, but we really needed to look internally at our own workflows and processes and operations to figure out what we needed to do to change in order to be part of that conversation.” In its approach to address social health, Humana sought programs and interventions that incorporated a social health lens to the work they do on an enterprise level. Six years after launching the Bold Goal strategy, the health plan has expanded to 16 communities, and by 2020 conducted 3.5 million SDoH screenings, provided 816,000 more healthy days for Medicare Advantage (MA) members in Bold Goal communities, launched strategic academic partnerships to support physicians, and delivered more than 1.1 million meals from March 2020 through the end of the year as a response to the COVID-19 pandemic. Additionally, to ensure a closed-loop referral system, Humana launched its Social Health Access Referral Platform (SHARP) project, a technology that allows care coordinators to screen for SDoH, better connect members to community resources that address social health, and then understand the impacts on members’ clinical health outcomes, explained Rivera. Through its partnership with the AACN and Signify, Humana was able to implement SHARP throughout the San Antonio community. Rivera credits Humana’s partnership with the AACN and Signify for the progress made so far. “We can’t do it alone; so, health care can’t drive this change just within the health care segment, community can’t drive that change just within the community segment,” she said. “This approach truly does allow us to keep the member at 14
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the center of everything we do because we’re untangling this current disconnect our members face when it comes to achieving their best health. Instead of putting responsibility on members to seek assistance and guide their own path, through the partnership with AACN and Signify, we are better able to direct our members to community resources.”
Independence Blue Cross’ CommunityLink Similarly, Independence Blue Cross launched its CommunityLink network in partnership with Signify in June 2020 to connect community organizations that aim to address SDoH in the Philadelphia area. As one of the poorest major cities in the United States, Philadelphia has many challenges, including SDoH, said Julia Weatherly Sr., GM Stars program analyst, Independence Blue Cross, noting many people struggle with social issues beyond financial restriction. “People knew SDoH existed in Philadelphia, but people weren’t so convinced that they existed for people who had private insurance.” Recognizing many of its Medicare members weren’t compliant with care measures such as mammograms or colonoscopies due to SDoH, Independence Blue Cross aimed to address the social and economic factors members faced. By developing its own SDoH questionnaire, the health plan was able to gain a deeper understanding of members’ social needs. The CommunityLink network currently consists of 16 organizations, composed of smaller and local organizations as well as those on a national scale. These organizations are among those that Independence Blue Cross Medicare members would be likely be referred to as well as the organizations that the community turned to in times of need, said Weatherly. “As we work through our members and we assess their needs, we’re starting to understand just how diverse people’s needs are in the Philadelphia area,” she said, noting the launch of CommunityLink amid the pandemic brought key social issues such as loneliness and mental health to light. So far, the community network has identified 3,200 needs and made 2,200 referrals to local organizations. In addition to supporting the people throughout the Philadelphia community, CommunityLink also aims to support the organizations, said Weatherly. “We really want to understand the needs of our community organizations and find ways that we can support them in either opening up and doing more services or what they need kind of on the back end, what they’d like to see from the platform, how we can enhance their overall processes to help people in the communities.
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