Some Notes on the RISE Nashville Summit 2016

by Kevin Mowll, Executive Director of RISE

The bigger this annual event gets, the more difficult it is to summarize all the themes and nuggets of information.  Perhaps the most useful place to start is with the keynote address by Senator Tom Daschle and some of the key ideas that emerged from the RISE Advisory Board meeting on Sunday, with thanks to Denise Tortora, our RISE / Healthcare Education Associates senior vice president of marketing for her notes, as well.

View from Capitol Hill and the Beltway - Senator Tom Daschle

Senator Tom Daschle gave an inspiring and insightful keynote address, demonstrating his keen understanding and appreciate of the essential issues in healthcare today as well as the political environment in which we are surrounded. The senator pointed out the critical factors of cost, quality, access and patient satisfaction on which there is fairly universal agreement regarding what ails our healthcare “system” in America (he challenges calling it a system as it has no coordination or governance).  He also laid out some scenarios for how public policy might shift depending on the 2016 elections coming up, and then held out some hope for certain themes that will survive no matter which party is in power next year.  Ultimately, there is no going back.  Whether or not “Obamacare” gets repealed, we have moved towards an accountable care paradigm along with the idea of getting health insurance coverage to more and more Americans.  He called upon us all to do our best to keep the momentum rolling.

Senator Daschle identified five primary factors driving changes in the healthcare environment:

  • Evolution of Big Data
  • Lack of interoperability – movement to greater transparency in measuring cost accurately
  • Migration away from fee for service
  • Movement to wellness and population health – smoking cessation programs, weight loss programs, etc.
  • Drive trends to Coordinated Care


He called out foreseeable trends:

  • More consolidations on horizon – hospitals and health plans
  • Public & Private HIX
  • Risk Sharing – ACOs
  • New cures – increase in chronic illnesses


Then he spelled out four tests for your organization:

  • How resilient are you?
  • How innovative are you?
  • How collaborative are you?  Break down those silos!
  • How engaged are you?



Health Insurance Exchanges and Marketplace

The insight on this topic is that the risk adjustment tool kit only gets you so far, even if you plan and execute at the highest level of best practices.  There still remains the critical issue of managing the cost of health care and achieving a viable medical loss ratio.  Some issuers seem to have placed all their eggs in the risk adjustment basket, hoping that the Three R’s will deliver them a profitable bottom line. In fact, without leveraging the information from the risk adjustment data to link back to care management, the QHPs stand a good chance of losing money.

In this line of business in particular, the member engagement strategy needs to be carefully crafted and employed right along in the new member onboarding process.  An effective outreach and intake process will be critical to getting influence over healthcare seeking behavior at the very beginning of the membership process.  Unlike Medicare Advantage, however, in the Marketplace, revenues are much leaner and companies are losing money. Highly efficient and effective methods must be used, therefore, to get an ROI.  But neglecting to do so is a perilous oversight.

It is something that must be leveraged and fully integrated into the new member experience with linkages to customer service, care management and pharmacy management. As we all know, the “spend” on specialty drugs and big ticket pharmaceuticals is a huge problem, so it needs to be tackled early on.


Medicare Stars, Quality and Accountability

Related to the HIX topic above, the critical factor is getting members brought into the healthcare process early and effectively in order to achieve measurable results which, in this area, revolves around HEDIS, CAHPS and HOS.  The difference between hitting the four star cutoff and missing it could be between survival and hitting the financial rocks. The same kind of issues will emerge on the HIX marketplace, too, as it witnesses reporting out on the QRS program in 2016. 

There is also a question about how to best engage members and whether the messaging is best from the healthplans or from the doctors.  Most would agree that when it comes to gaining compliance with healthcare issues, the patients want to hear it from their doctors.  Yet the providers are not always well-equipped to conduct that kind of sophisticated outreach campaign and manage it effectively.  It is one thing to connect with a member via phone or e-mail, but it yet another thing to achieve the desired result of follow through with getting the services needed.  The motivation and follow through are the weak points that undermine the healthplans’ results.  More collaboration needs to be achieved between healthplans and providers, along with an integrated set of capabilities that make the efforts seamless and successful. 


Risk Adjustment

The blocking and tackling of risk adjustment is a fairly well-understood process, for the most part.  There is a “machine” that manages the inputs and outputs as well as the process in between. However, significant business risks are posed with regulatory requirements and changes to the oversight and auditing process.  At a root cause level, the biggest flaws occur at the beginning of the whole process:  at the provider offices.  If robust ICD-code capture does not happen in the first place, and secondly, if the chart documentation is not adequate to pass a RADV audit, all the work downstream at the healthplan will still come up short and expose the plans to risks of big penalties.

On the HIX side, of course, there is going to be 100% RADV for the first time now.  On the Medicare Advantage side, rather than just 30 healthplan contracts being audited, CMS is proposing to radically expand the scope through RAC contractors.  In addition, for the first time, it appears that CMS is actually going to conduct extrapolation penalties, which geometrically expands the scale of the financial risks to the MA plans. 


Provider Transformation from Volume to Value

As CMS pushes to shift provider payment from the volume side of the spectrum to the value end, it becomes apparent that the largest part of the physician practice community has significant challenges to adapting to the new realities.  While some markets like Southern California, Florida, and certain other metropolitan areas have aligned physician networks with experience in this arena, most provider groups are still primarily working on a productivity formula and fee for service payments. 

There is an enormous game of “catch-up” that must be played out, particularly as a large swath of providers are now in ACOs and the next generation ACO models with Medicare, as well as with some commercial PPO business.  The infrastructure is really lacking and there is an enormous appetite for practical knowledge of “how to” in these areas.  

Tags: risk adjustment, CMS, HIX, Providers

Log on to Your Rise Account

Forgot your password?
Create an Account

Association Sponsors

Latest Posts

Keep M.E.A.T. on Your List for a Healthy Audit

By Jeanmarie Loria, Advize Health, LLC If you’re reading this article, chances are you already know what HCC Coding is – but we’ll give you a refresher anyway. Hierarchical Condition Category (HCC) and Risk Adjustment Coding is a CMS-mandated payment model. This model works to identify those with chronic and other serious illnesses and prescribes a risk factor score to each patient, taking into consideration their ailments and other demographics. With every payment model comes a specific set of audit and review requirements that must be met to maintain the integrity of the system, and this is where MEAT (Monitor, Evaluate, Assess/Address, Treat) comes in handy. In a face to face visit M.E.A.T. maybe found in the chief complaint, history of present illness, review of systems, physical exam, assessment and/or plan....
Read More

Getting It Right: True North in Healthcare Reform

The movement to repeal and replace "ObamaCare" created so much political noise that clear thinking has been hard to come by. The 2010 legislation that created the marketplace for individuals and small business (the Affordable Care Act or ACA), has almost evolved into a political Rorschach test. The more that politicized options and alternatives to repealing, replacing, or repairing it were discussed, the harder it was to put into focus the original problems the legislation was designed to address. Nevertheless, the rancorous divisions over what needs to happen to fix problems in the individual insurance market remain a distraction from the real issue at hand: the cost of healthcare weighing down the economy and what we need to do to fix it. With all the intense debates swirling around this topic, an impression emerges that “solving the ObamaCare issues” is something that must be accomplished as an isolated matter, discrete and independent of other problems. The heated debates concentrate on the mechanics and tactics required to solve the "uninsured problem", the "under-insured problem", and for some, the federal budget problems created by the subsidies for low-income enrollees in these plans. This single-issue mono-vision obscures a reality that must be addressed. This perspective completely misses the fact that something is going on that is far more corrosive to the wellbeing of all of us as consumers of health care, as taxpayers, and as a nation: something that overshadows the tug ‘o war over ObamaCare. The critical and overlooked issue is that health care expenditures in the U.S are at least twice as expensive as other nations, which consume so much of the national economy...
Read More

Upcoming Conference


Qualipalooza: The 2nd Annual RISE Quality Leadership Summit 

This unique event incorporates three conferences presented side-by-side: the Star Ratings Strategic Planning Forum, the HEDIS Forum, and the CAHPS, HOS & Member Survey Forum. Register for one conference for an in-depth examination of a single area, or design your own event by opting for the all-access pass and choosing the sessions from each conference which correspond exactly to your interests.


Upcoming Webinar

Successful and Meaningful Techniques for Integrating Risk and Quality Interventions

Quality measurement and risk adjustment regulations are increasing and the financial impact upon health plans is progressively driving accountability and influencing profitability through payments, penalties, and bonuses. To improve performance and optimize risk and quality payments, Health Plans need to streamline processes, employ best practices for data capture, and focus on strategic interventions that use a member-centric approach.  

Connect With Us

Copyright © 2014 Resource Initiative & Society for Education. All rights reserved.