OIG: Risk mindfulness and what’s coming down the pike
During a keynote address, Carolyn Kapustij, senior advisor for Managed Care at the OIG, provided an update on current focus areas at OIG, recent findings, and what’s ahead.
Sharing a bit about OIG’s strategic plan, Kapustij discussed managed care as a priority area, given its growth, and the kind of impact the agency wants to have— emphasizing the importance in protecting access to care, with particular focus on prior authorizations and denials, as well as protecting the financial integrity of programs. She stressed that OIG encourages plans to look at the data coming in and to look for specific circumstances where errors occur, such as the diagnosis not matching the code.
Looking ahead at what's upcoming at OIG, Kapustih said the agency will be focusing on new types of audits and evaluations, including supplemental benefits review, MA efforts regarding reducing health disparities, and use of prior authorization in post-acute settings.
She closed with a message for compliance—develop a culture of compliance to instill trust in MA plans. Compliance is key, she said, and there's value in allowing people to come forward and report issues. People in your plans care about compliance; tending to it will reap benefits even though it’s difficult.
Leadership panel offers strategies to navigate the everchanging environment of RA and quality operations
We heard from a leadership panel who offered their perspectives on MA operational excellence in a post-Final Rule era, diving into how they are balancing financial considerations with best-in-class patient care and the strategies they’ve found successful to increase plan revenue, both on the RA and quality side.
While discussing headwinds they’re facing going into 2025, the group shared several concerns, including inflation, drug prices, premium cuts, and a lack of resources. The market is switching, and it’s critical to become more agile, explained Rebecca Welling, vice president risk adjustment, Intermountain Health.
Given these changes in the market, shared risk is going to be the path forward, said Liz Haynes, MSN, RN, CCM, DVP, risk adjustment & Stars government programs, Blue Cross and Blue Shield of Kansas City, noting that providers are going to have to look at prescribing and all facets to reallocate dollars to support prescription drug changes.
When it comes to the programmatic approaches the panelists have found successful, they shared similar sentiments in the importance of collaborating with vendors, presenting data through dashboards to providers, and creating awareness around equity.
Industry leaders share their innovative approaches to scaling SDoH programs for the aging population
During a panel discussion on scaling SDoH programs for the aging population, Highmark Health, Independence Blue Cross, and CalCAPA shared their innovative approaches in addressing SDoH needs for this population across all lines of business—commercial, MA, Medicaid, and SNPs.
While discussing the biggest gaps and hurdles as they pursue their health equity strategies, the panel stressed the ongoing challenge in capturing data on social needs.
While engaging with community-based organizations (CBOs) is critical to address SDoH, they need funding to take on that work. And while there is ROI in those partnerships, it’s hard to show without the data, further driving the data/funding dilemma.
“It’s a game to figure out how to give money to CBOs,” said Dr. Seun Ross, executive director, health equity, Independence Blue Cross.
When it comes to supplemental benefits to support aging in place, the panelists shared several strategies. Engagement is a leading one, according to Ross. “Our ability to engage on SDoH will determine success,” he said, adding that working with vendors and holding MA events throughout the communities has been beneficial for Independence Blue Cross.
A particular focus on efficiency is also key, added David Knight, executive director, CalCAPA. When working with vendors or CBOs, he emphasized the importance of looking at what everyone is already doing to streamline and avoid redundancy.
During their final discussion on approaches to optimizing the health equity index, they reiterated the need for engagement around SDoH. “Health equity— it’s about engagement, it’s about member experience,” said Knight.
A special presentation from seasoned Paralympic Swimmer and Inclusivity Expert Jonathan Heider Laedtke
In our final general session of the day, Paralympic Swimmer and Inclusivity Expert Jonathan Heider Laedtke shared his inspirational story of building resilience against all odds.
He was born during the Croatian Civil War of Independence and his biological family placed him in an orphanage, unable to care for a baby with no arms or legs. It wasn’t until a Catholic nun from Wisconsin on a mission trip to Croatia visited the orphanage and contacted a family in Green Bay, Wis. she knew wanted to adopt a child with special needs and asked if they’d consider adopting him. Their “yes,” sight unseen, changed his life forever.
A high-energy kid who needed an outlet, he tried a variety of sports and extracurriculars. It was swimming that stuck and continued to play a pivotal role in his life. He started competing at age 12, quickly rising to the national level and spurring his career as an elite athlete.
While Laedtke always felt very seen and supported by his coaches and fellow athletes, it wasn’t always that way when it came to navigating the health care system, which he said always posed a “risk of slipping through the cracks.”
During his fireside chat with Jenn Kerfoot, chief strategy and growth officer, DUOS, Laedtke shared how the health care system could ensure people are not left out. Technology to enable freedom is a huge component, he said, however, he also urges caution with AI, noting the human touch component is still so important.
When asked about the one change he’d like to see, it’s for people to continue to educate themselves and connect with organizations supporting individuals with disabilities. People with disabilities are scared of the health care machine, he said— show who you are, show your interest, and show your humanity.