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  Whether or not “Obamacare” gets repealed, we have moved towards an accountable care paradigm along with the idea of getting health insurance coverage to more and more Americans.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

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