nº6 - Fall 2019
SECRET SHOPPER STUDY
Read the key takeaways from a health plan’s ‘secret shopper’ pilot and the lessons learned on member engagement Click to see other articles
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CMS star ratings update: Members get greater access to higher-rated MA-PD plans
RISE: Small MAOs face unfair financial risks under CMS proposed changes to Medicare Advantage RADV audits RISE applauds CMS’ move to expand star ratings to plans on the ACA exchanges
The National Population Health Summit: Jason Helgerson on trends in population health and the move to value-based payment RISE recommended reading: United Hospital Fund’s white paper on the social determinants of health Customer experience expert Jeff Tobe offers insight on member engagement
Judge gives Trump administration the green light on sale of ‘skinny plans,’ ACAP vows to appeal ruling RISE West 2019: Keynote presenters inspire with leadership lessons, problem-solving strategies
New federal initiatives expand benefits for effective risk adjustment Health Fidelity
What health care executives must know about the interoperability and patient access rules Cognizant Data-driven consumer experience: Leveraging artificial intelligence to improve patient outcomes Inovalon CFOs no longer rely on PBMs to provide the objective pharmacy reporting, analytics, and benchmarks needed to control costs Pulse8 HEDIS® 2020: How health plans can impact the opioid epidemic through preventive measures SS&C Health How to make social determinants of health actionable Oliver Wyman, Lincoln Financial Group, and Welltok New plan flexibility for Medicare Advantage brings opportunities for supplemental benefits and Part D drug coverage in 2020 SS&C Health
RISE recommended reading: Deft Research’s blog post on social determinants of health and health outcomes 7 lessons learned from the 2019 Medicare OEP
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Letter From the Editor:
WHAT I’LL TAKE AWAY FROM RISE WEST 2019
Ilene MacDonald Editorial Director, RISE
Since joining RISE last year I’ve had the pleasure of interviewing experts in risk adjustment, quality improvement, and value-based care, as well as attending RISE conferences where I’ve heard dynamic keynote speakers and met our members who shared their challenges and success stories. I’ve learned from all these experiences. But I’ve never been more moved or inspired than hearing the first-hand account of Richard Picciotto, the retired NYC fire department chief who was the highest-ranking firefighter to survive the collapse of the World Trade Center’s Twin Towers on 9/11. He recounted his amazing story of leadership and survival at RISE West 2019 on Sept. 10, a day before the 18th anniversary of our nation’s darkest day when terrorists launched coordinated attacks that killed nearly 3,000 people. He is credited with saving thousands, making the difficult call to abandon the rescue mission and evacuate the North Tower after he heard and felt the impact of the South Tower collapse. But Picciotto said he was one of many heroes that day. As he made his way up 35 floors to rescue those trapped on the upper floors, he recalled watching people helping one another, such as the group of able-bodied coworkers carrying a person in a wheelchair down the narrow stairwell to safety. People who never met one another before but were trapped on the same floor vowed to stay together until they all could escape. You can read the details of his keynote presentation in my article on the RISE site here. But what struck me most: Picciotto’s recollection of the kindness that people showed to one another after 9/11, the care they offered to survivors and the widows and widowers of those who perished in the attacks. The country was united then. Reflecting on today’s partisan divide, Picciotto said he thinks people have more in common than they realize. Our differences, he said, are minor. And in the face of tragedy, history shows Americans are there for one another.
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Note from the Director:
RISE WEST REVEALS THE INCREASING DEMAND FOR PAYER-PROVIDER COLLABORATION
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t our annual RISE West conference in San Diego last month, I noticed how engaged and energetic our audience was amid the conversations involving the evermore complex issues of our industry. We witness the increasing demands for more information needed to fulfill the expanding roles of the accountable organizations in our space. From providers to plans to vendors, this drive forward demands more and more every day. Yet, in some ways, the weight of these demands seems to bear down on the office practices of physicians doing their best to provide care to their patients. Not long ago, the administrative burdens they bore involved capturing procedure codes, verifying insurance, and submitting claims. Now they are necessarily part of a larger system of care that is accountable for quality, access, and cost. And in turn, they must adapt themselves to the demands of that system for greater diagnostic information and its accuracy. Not only that, but they must also submit to scrutiny for all those dimensions of evaluation and assessment at risk for their value-based payments.
As the social determinants of health are becoming the newest point of concern, the complexity for physician practices has just dramatically expanded. How can this possibly work? In a paper published by the United Hospital Fund, the nuts and bolts required to support referrals from physician practices to community-based resources is spelled out in compelling detail. It becomes obvious to me that the linkages between health plans and providers must be further expanded and deepened to supply the tools and utilities necessary to execute on these new demands. Not only that, but a thoughtful redesign must be accomplished to help protect and buffer the ways in which these new demands impinge on the doctor/ patient experience in the office practices. Collaboration is necessary to simplify, streamline, and standardize at the risk of eroding the quality of care at its very heart. We view the role of the RISE organization as a facilitator and convener of audiences to have the kind of conversations and professional interactions necessary to map out strategies and to share best practices
around making these collaborations happen successfully. It is our hope that, like RISE West, we can be the host to the creative process, the exploration and discovery of new ways to figure out how to make this work more effectively for all the stakeholders. By bringing together the providers, the plans, the community-based organizations, and the vendors, we hope to act as an accelerator and an incubator. Stay tuned for more news and ideas on this topic going forward. By bringing together the providers, the plans, the community-based organizations, and the vendors, we hope to act as an accelerator and an incubator. Stay tuned for more news and ideas on this topic going forward.
Kevin Mowll
Executive Director, The RISE Association
It is our hope that, like RISE West, we can be the host to the creative process.� 4
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3 TAKEAWAYS
Lessons learned from RISE West 2019 on provider engagement, payer-provider collaboration, and the real reason seniors choose MA plans
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AN DIEGO—More than 450 attendees gathered at the Loews Coronado Bay Resort in San Diego for RISE West 2019 to learn about payer/provider collaboration, leadership, and the member experience. Below are takeaways from select sessions:
Seniors reveal star ratings are not a big factor in plan choice Nine seniors participated in a focus panel moderated by Kathleen Ellmore, managing director of Engagys, to provide insight into their experiences with the Medicare and Medicare Advantage markets. One of their biggest reveals may be a bit discouraging for health plans that have worked hard to achieve a 4- or 5-star rating: The number of stars didn’t factor into their decision to pick a plan. Indeed, seven out of the nine seniors said they never heard of stars. The two who did
hear of the them said they didn’t consider and the quarterly OTC benefits. them when choosing their plan. “I love that there is a recognition of being What does seem to matter: Cost, healthy, and they continue to give me the supplemental benefits and a personal touch. option to stay healthy,” he said. “It’s been a great motivation.” For example, one senior said he picked his plan because it included a gym membership, Provider engagement should be a as well as benefits for over the counter (OTC) ‘team sport’ and a partnership prescriptions, contact lenses, and dental care. Another complained she is paying more in Cheryl Babo, director of risk adjustment, premiums this year but was frustrated that it Stars and provider engagement, Regence didn’t offer a silver sneakers program. Health Insurance, presented a program on how to revolutionize your quality strategy Another said he is totally satisfied with his through enhanced provider engagement. plan. He was especially impressed that the Her advice is to not think about it as a carrier provided a breakfast where he could separate department. Rather, consider it a get more information. He felt good about team sport in which everyone participates, the time they invested in him, especially and no one is a spectator. when a sales person gave him a business card with his personal cell phone number if Above: Nine Medicare and Medicare he had further questions. Although he’s been Advantage beneficiaries joined Kathleen on Medicare Advantage for 18 months, he Ellmore (front row, second from left) for the has only used the Silver Sneakers benefit focus panel. Click to see other articles
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...we see compliance and ethics as a team sport, and we are trying to implement a similar culture for risk adjustment, quality, and Stars so everybody understands that they are part of the game.” “At Regence we see compliance and ethics as a team sport, and we are trying to implement a similar culture for risk adjustment, quality, and Stars so everybody understands that they are part of the game,” she said.
noting sometimes health plans make the mistake of telling physicians and providers what to do and what they need from them. Instead, she recommended that they listen to what the providers need from them.
This means leveraging your internal relationships to get them engaged in activities. If you don’t develop those relationships, your success rates won’t be as high, Babo said.
Donna Malone, PC, CRC, senior manager of enterprise risk adjustment, HCC coding and quality assurance, Tufts Health Plan, also noted that health plans sometimes interpret the phrase provider education too literally. Providers have been to medical school and know how to care for patients. Instead, she said plans need to focus on the fact that providers are already doing the work. They just need to explain why and how providers can capture that work, so they get credit for it.
interest in mind of the patients, nothing will move forward,” Howell said. However, if a payer focuses on patient outcomes as its true mission, it will align with the goals of physician leaders, and you can use that as a platform in negotiations. “At the end of the day their goal is to improve the quality of care of their patients, not to make the health plan richer,” she said.
Howell encouraged plans to create a buddy system and provide physicians with the name and home and cell phone number of someone from the payer side that they could call when they have a question. “It’s as simple as that to start building trust…Part of communication is sharing information. Buddy groups do work,” she said, noting that But without trust, payer-provider the partner can call his or her payer partner collaboration will never happen to find out what they really need to do to improve programs, such as star ratings and Amy Nguyen Howell, M.D., chief medical medication adherence. Shannon I. Decker, Ph.D., executive officer for America’s Physician Groups, the director of risk, NAMM California, part of largest professional association representing OptumCare, UnitedHealth Group, agreed, physician organizations across the country, said research shows that true payer-provider collaboration leads to improved patient outcomes. Instead of volume, collaborative payers reward providers for increasing the value of care. They care about the primary care provider’s outcomes because their economic fates are tied together. Part of the problem is that providers are often looking at multiple programs and getting different messages, according to Stacy Garrett-Ray, M.D., vice president, medical director, population health services organization, president, quality care network, University of Maryland Medical System, who spoke about provider engagement during a separate session. She suggested finding ways to align those messages.
But trust is vital to foster and help execute collaboration between payers and providers. “If you don’t take the time and energy in building trust between a provider group and payer, it’s not going to work,” she said. She advises health plans to begin building the foundation of trust by thinking about what motivates physicians. Not everyone is motivated by money, but one commonality that all physicians share is that they have built their careers around their patients. They care about patient outcomes. “If a physician group doesn’t trust that you have the best 6
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If a physician group doesn’t trust that you have the best interest in mind of the patients, nothing will move forward.”
BCBSNJ’S SECRET SHOPPER PROGRAM
IMPROVING PATIENT CARE & MEMBER ENGAGEMENT Click to see other articles
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teven R. Peskin, M.D., executive medical director of population health, Horizon Blue Cross Blue Shield of New Jersey, talks to RISE about the key takeaways from the health plan’s secret shopper pilot and the lessons learned on member engagement. Peskin will present a case study on the program at RISE’s 9th Annual HEDIS® & Quality Improvement Summit, Oct. 23-25, in Miami.
“Secret shoppers” may hold the key to improve quality and increase evidencebased screening for primary prevention. That is one of the takeaways from a twoyear pilot program at Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) which used trained actors to pose as patients to evaluate the care that physicians gave in the insurer’s value-based care program. The research was led by Saul Weiner, M.D.,
and Alan Schwartz, Ph.D., founders and principals of the Institute for Practice and Provider Performance Improvement (I3PI) and funded by a grant from the Robert Wood Johnson Foundation.
“They were really open and receptive to it,” said Peskin. When we were recruiting for participation, I was quite concerned we might have to do arm twisting because it’s disarming to have a fake patient, a spy come in to your office. But we had more Peskin said that while secret shoppers often physicians raise their hands than we had evaluate customer service in restaurants, slots available.” hotels, and retail stores, the pilot program at Horizon was the first time a large health Although nearly 60 physicians and nurse insurer used unannounced standardized practitioners agreed to participate in the patients (USPs) to directly observe physician- program, they had no idea who the USPs patient interactions, and that information were or when they arrived at the office. The was used to help physicians improve the care USPs presented themselves as real patients they provide. and audio recorded the visits. Researchers then reviewed the recordings as well as the Peskin thought the biggest hurdle would be doctor notes from the patients’ medical getting physicians to agree to take part in records. the program, but he was pleasantly surprised by their interest. Researchers focused on conditions that contribute to rising health care costs, including diabetes, cancer care, asthma, back
I was quite concerned we might have to do some arm twisting because it’s disarming to have a spy come in to your office.”
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pain, and depression. They used evidencebased standards to develop a checklist that physicians were to follow. The USPs had four visits with each of the participating physicians: two base line visits and two post-intervention visits. Later the researchers scheduled phone calls with the physicians and nurse practitioners to review the findings and identify opportunities for improvement.
KEY FINDINGS Physician behaviors improved in several areas after they received feedback from the secret shopper study.
Chronic pain management Horizon’s goal was for physicians to follow evidence-based management of non-cancer chronic pain and reduce opioid prescriptions. Doctors were to provide patients with education about the dangers of opioids and prescribe non-opioid alternatives or physical therapy. Participating physicians initially followed the recommendations 74 percent of the time. With feedback, adherence to the recommendations increased to 84 percent.
Tobacco cessation
care plan. Before the pilot, they did so 51 Pictured above: Steve Peskin percent of the time, and after feedback, it dropped to 49 percent.
Cancer screenings Horizon’s goal was for providers to address patient misconceptions about cancer screenings. Prior to the pilot, physicians recommended screenings 39 percent of the time. Post-intervention that figure dropped to 35 percent, but there was a slight improvement in getting providers to identify the reason the patient was resistant to cancer screening. Prior to the pilot, they did so 27 percent of the time. After the pilot, it increased to 29 percent.
Physicians are also encouraged to follow evidence-based recommendations and advise patients to quit smoking and discuss cessation strategies and medications. Prior to the intervention, physicians followed the OVERALL OUTCOMES recommendations 24 percent of the time. Post-intervention, adherence increased to 57 But the most powerful outcome, Peskin said, percent. is that not only did researchers directly observe better care post-intervention, they Depression screening also saw improvements in the total care for Before the USP pilot, providers used an all patients—not just with the secret shoppers. evidence-based instrument to screen patients for depression 52 percent of the Peskin believes the secret shopper project time. Following feedback from the study, has the potential to improve the patient physicians used the tool to screen for experience and patient safety, and close gaps in care. The results can be far more powerful depression 70 percent of the time. than what health care organizations usually get from patient surveys. Medication adherence This was an area that didn’t show significant “We did it in primary care, but it could be improvement. Indeed, prior to the pilot, applied in urology, cardiology, and other physicians identified the reasons the patient domains,” he said. didn’t take his or her diabetes medication 59 percent of the time. After the pilot, that figure remained 59 percent. Providers are also to address barriers to adherence in the
...not only did researchers directly observe better care postintervention, they also saw improvements in the total care for all patients— not just with the secret shoppers.”
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MARTIN BLOCK AWARD NOMINATIONS
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RISE is now accepting nominations for the 2020 Dr. Martin L. Block Award for Excellence and Innovation. The prestigious award is given to an individual who has advanced the lives of America’s seniors through clinical leadership, policy vision, and by superior example. Nominations will be accepted through Dec. 31, 2019 and the award will be presented at RISE Nashville 2020, the annual Medicare Advantage mega conference, at Music City Center, on Monday, March 16, 2020.
Eligible nominees must: •
Work within the clinical field as an MD, NP, RN, PA, DO or otherwise clinically credentialed
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Work for a health plan, provider, accountable care organization, or vendor/supplier to the health care marketplace
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Have fulfilled one of the following criteria: Pictured above is 2019 Martin Block award winner, Mark Dambro, M.D., senior vice
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Contributed to significant process improvement in the quality of clinical care provided to health plan members
president of health informatics for Signify Health.
Dr. Block, or Marty, graduated from Northwestern University Medical School with a Doctor of Medicine degree. He completed his internal medicine residency in 1978 at Washington University in St. Louis and began his private practice in Riverside, Nominations must be submitted by Monday, Calif., where he was active in the medical Dec. 31. Click here for nomination forms. community. •
Dedicated more than 10 years to clinical practice or the administrative support of related job functions that improve clinical quality outcomes
About the Dr. Martin L. Block Award
quality and outcomes management. He eventually moved to Scottsdale, Ariz., and went on to earn several awards for his dedication and passion. Dr. Block died in October 2013 of brain cancer at the age of 62. In recognition of his contributions to innovations in risk adjustment, and to honor his life’s work, the RISE Association named the award in his honor and posthumously recognized him with the first Martin L. Block Award in March 2014.
Dr. Block’s focus on delivering quality patient care led him into healthcare administration early on in his career. As doctor of 35 years, his dedication to improve medicine fueled his rise among the ranks of several major health plan management companies, including Previous award winners include Mark Blue Cross Blue Shield, Cigna, Aetna, and Dambro, M.D., senior vice president of health United Healthcare. informatics for Signify Health, Dr. Manjusri Vennamaneni, chief medical director and No matter his title–medical director, chief chief quality director for Access Health medical officer or vice president of clinical Care Physicians, LLC.; Michelle Lupoli, R.N. services–he stayed fixated on his mission vice president of medical management for to improve quality of care, and he worked Neighborhood Health Plan of Rhode Island; The award is given in honor of the late long hours every day to develop and and Dr. John Broderick, regional medical Dr. Martin Block, pictured right, a regular improve processes that benefit patients and director of Landmark Health. speaker at the RISE Nashville Summit, and healthcare professionals. an expert in the risk adjustment industry who had a natural ability to engage and inspire As a certified professional coder, Dr. Block Click to Nominate audiences and a passion to improve patient gained critical insights into risk adjustment, care. Click to see other articles
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UPCOMING EVENTS
March 15-17, 2020 in Nashville, TN
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