Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and
business strategies about Medicare Advantage plans, product design, marketing,
enrollment, market expansions, CMS audits, and countless federal initiatives in
MA and Medicaid managed care.
By Lauren
Flynn Kelly, Managing Editor
July 21, 2016 Volume 22 Issue 14
When it comes to managing risk and closing gaps
in care, the solution isn’t always as simple as targeting the costliest
members. Health plans and their vendor partners can implement tailored
strategies that include sharing risk with providers, leveraging community
partners and using data to identify those members at the highest risk for noncompliance
and costly claims, according to two speakers who gave separate presentations at
the Medicare Advantage and Medicare Summit of the 12th Annual Government Health
Care Congress, held July 12 and 13 in Tysons Corner, Va.
Dianna Chautin, vice president of provider
relations at UnitedHealthcare and a former HealthSpring executive, recommended
designing incentive programs around “a certain segment of your population that
are going to drive the most costs,” such as those with diabetes or congestive
heart failure, who typically have some compliance issues. For example, through
a partnership with Wal-Mart Stores, Inc., UnitedHealthcare offered a “Coupons
for Care” program to Medicare Advantage plan members in Tennessee that supplied
transportation to and from Walmart stores where diabetic members could redeem
coupons for eye exams. The program helped the insurer meet star ratings goals
by filling gaps in care and increasing compliance with eye exams by about 50%.
Beneficiaries received Walmart gift cards for
participating in the eye exam program. Chautin added that in her experience,
when offering gift cards, $25 appears to be the minimum threshold that triggers
a response from members. Partnering with local retailers, pharmacies and
walk-in clinics are all great ways to reach members, she said.
In her former role at HealthSpring, Chautin
added that the insurer encouraged providers who get paid a fee for completing
annual wellness exams to take a portion of that and pay their “midlevels” such
as nurses and nurse practitioners for completing the forms. For example, if
they get paid a $75 fee, the insurer would advise providers to “peel off” $25
to the midlevels, which boosted participation.
Taking that involvement with providers one step
further, Chautin suggested that Medicare plans pursue a capitation model in
which the provider takes full risk, which she has seen result in physicians
using some very “creative” ways to improve care and lower overall costs for
their patients.
For example, a network physician in Memphis had
a patient who was an emergency room “frequent flier,” which in that area costs
about $10,000 per ER visit. Since that was going to impact the practice’s
bottom line, UnitedHealthcare shared that information with the provider and the
provider started seeing that patient in the office every day, which stopped him
from going to the ER. “He felt like if he took that capitation money, every ER
visit he saved was going to result in productivity and some profit for his
practice, and it really worked, [and] the patient had a great outcome,” said
Chautin. “I know not everybody is going to be willing to do that, but it made a
difference.”
Another example was a patient who kept going to
the ER for infections. A case manager sent by UnitedHealthcare went to the
patient’s home and found unsanitary living conditions. The provider chose to
use some of the capitation money to pay for cleaning services on a monthly
basis and saw those infection-related ER visits drop. “There are a lot of ways
to approach these things and if you give physicians the power to do that and
they have risk for that patient, they can figure out some creative ways to use
those capitation dollars.”
MissionPoint Offers Transition Support Services
Likewise, MissionPoint Health Partners works
with physicians serving certain segments of a plan’s population to identify the
“root cause” of some issues that are driving cost, explained Jordan Asher,
M.D., chief clinical officer and chief innovation officer with the population
health management company.
Owned by not-for-profit health system Ascension,
MissionPoint focuses on six markets, including Medicaid plans and Medicare
accountable care organizations, and operates four separate teams of “health
partners” that include everyone from case managers to pastoral care providers
to meet patients’ unique needs, whether they’re transitioning from the hospital
to the home or in need of chronic disease management. For example, the vendor
has transitional health partners working inside MA Special Needs Plans.
MissionPoint utilizes data from a variety of
sources to identify not just the most expensive patients but to focus on those
who present the greatest risk of moving into the “high-cost” bucket. “People
move in and out of these buckets, so what we really want to do is figure out
which ones are going to go to that [high-cost] bucket and prevent it, and
[support the providers of those members who] are staying in that bucket,” he
said.
For example, the company identified two primary
care practices in a plan’s network that were demonstrating rising per-member
per-month costs, high avoidable hospital admissions and high emergency
department admissions per 1,000 patients. MissionPoint showed the physicians
which patients were leading to those high-cost claims and worked with the
members to provide some of the support services offered by its teams to produce
dramatically different numbers a year later, said Asher.
Data is a key driver in all of these efforts,
and MissionPoint doesn’t just look at clinical and administrative data, but
considers environmental, behavioral, demographic and health partner data, he
added. Pharmacies serve as ideal health partners for gaining additional insight
into what’s happening with an elderly patient because of their frequent
face-to-face interactions and claims history, weighed in Chautin.
https://aishealth.com/archive/nman072116-02?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=114150343
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