Integrating risk and quality 18 jan12

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Presentation given at Medicare Revenue Management meeting, The Reach Resort, Key West, January 18, 2012

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Integrating risk and quality 18 jan12

  1. 1. Integrating Risk Qua lityRisk andQualityBenefits of this Critical MergerWayne Pan, MD, MBAChief Medical OfficerPacific Partners Management Services, Inc. Medicare Revenue Management • The Reach Resort, Key West • January 18, 2012
  2. 2. ?
  3. 3. Adjusting your MLR labels so that you get payment forhealth care costs that then fund your quality programsMarrying qualitative goals with quantitative goalsProviders and health plans influencing each other’sstar ratings: How high is high enough to lift up thatpoor performer and how low is low enough to squeezethem out?Tying your satisfaction surveys to CAHPS surveys –using the same language in your in-house surveys togroom your members for positive feedback andhelpful mock resultsWhether or not to absorb the member’s co-pay if thatprevents them from getting care and providing riskadjustment opportunities
  4. 4. MLR: medical loss ratio medical expenses premiums collected
  5. 5. MLR: medical loss ratiomedical expenses admin expensespremiums collected + premiums collected = 1
  6. 6. MLR: medical loss ratiomedical expenses admin expensespremiums collected + premiums collected = 1
  7. 7. Limits premiums: 118% of medical losses (85%) 125% of medical losses (80%)
  8. 8. INNOVATION?
  9. 9. MLR: medical loss ratiomedical expenses admin expensespremiums collected + premiums collected = 1
  10. 10. admin expenses: admin ratio + profit margin
  11. 11. MLR: medical loss ratiomedical expenses admin expensespremiums collected + premiums collected = 1
  12. 12. medical expenses: incurred claims expenditure +“activities that improve healthcare quality”
  13. 13. make patients sicker?
  14. 14. get sicker patients?
  15. 15. quality: case management/care coordination chronic disease management medication/care plan compliance reduction of disparities quality reporting/documentation accreditation fees directly related to qualityhospital readmission prevention/discharge planning patient education and counseling promotion of patient safety and error reduction prospective drug utilization review wellness and health promotion programs wellness assessments/coaching rewards to members
  16. 16. the argument for quality
  17. 17. What does 2qualitymean you?
  18. 18. measurement?improvement?
  19. 19. startwithwhy
  20. 20. whysmen
  21. 21. 5 whysmen
  22. 22. whywhywhywhywhy
  23. 23. patient
  24. 24. beginsandends
  25. 25. patient
  26. 26. think what program fro m in si de how process ou t why patient adapted from Simon Sinek, “Start with Why,” (2009)
  27. 27. patientcenteredness
  28. 28. “how will the patient benefit from this?”“does this make it easier for the patient?”
  29. 29. Adjusting your MLR labels so that you get payment forhealth care costs that then fund your quality programsMarrying qualitative goals with quantitative goalsProviders and health plans influencing each other’sstar ratings: How high is high enough to lift up thatpoor performer and how low is low enough to squeezethem out?Tying your satisfaction surveys to CAHPS surveys –using the same language in your in-house surveys togroom your members for positive feedback andhelpful mock resultsWhether or not to absorb the member’s co-pay if thatprevents them from getting care and providing riskadjustment opportunities
  30. 30. Adjusting your MLR labels so that you get payment forhealth care costs that then fund your quality programsMarrying qualitative goals with quantitative goalsProviders and health plans influencing each other’sstar ratings: How high is high enough to lift up thatpoor performer and how low is low enough to squeezethem out?Tying your satisfaction surveys to CAHPS surveys –using the same language in your in-house surveys togroom your members for positive feedback andhelpful mock resultsWhether or not to absorb the member’s co-pay if thatprevents them from getting care and providing riskadjustment opportunities
  31. 31. Risk lity Qua
  32. 32. we are herefrom: missclaudiawong.blogspot.com (January 30, 2011)
  33. 33. 4x4 healthcare
  34. 34. 4processes x4dimensionaldata
  35. 35. communicationanticipation collaboration Case Managers Patients PCPs Specialists coordination
  36. 36. qualityprocess
  37. 37. riskadjustmentprocess
  38. 38. patient doctor documentation
  39. 39. patient doctor documentation same
  40. 40. quality: CMS 5 STARrisk adjustment: HCC
  41. 41. $$$$$$
  42. 42. revenuemanagement
  43. 43. whatabouttheexpensemanagement?
  44. 44. whataboutmedicalmanagement?
  45. 45. whataboutcarecoordination?
  46. 46. Adjusting your MLR labels so that you get payment forhealth care costs that then fund your quality programsMarrying qualitative goals with quantitative goalsProviders and health plans influencing each other’sstar ratings: How high is high enough to lift up thatpoor performer and how low is low enough to squeezethem out?Tying your satisfaction surveys to CAHPS surveys –using the same language in your in-house surveys togroom your members for positive feedback andhelpful mock resultsWhether or not to absorb the member’s co-pay if thatprevents them from getting care and providing riskadjustment opportunities
  47. 47. Adjusting your MLR labels so that you get payment forhealth care costs that then fund your quality programsMarrying qualitative goals with quantitative goalsProviders and health plans influencing each other’sstar ratings: How high is high enough to lift up thatpoor performer and how low is low enough to squeezethem out?Tying your satisfaction surveys to CAHPS surveys –using the same language in your in-house surveys togroom your members for positive feedback andhelpful mock resultsWhether or not to absorb the member’s co-pay if thatprevents them from getting care and providing riskadjustment opportunities
  48. 48. networkconsiderations
  49. 49. networkmanagement
  50. 50. behaviorchange
  51. 51. put hot triggers in the path ofmotivated people BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
  52. 52. incentivealignment
  53. 53. incentivetiming
  54. 54. Have you seen ANSWERS? 6-month old lab mix well-trained to do old tricks, not so good with new tricks
  55. 55. healthplans
  56. 56. healthcareproviders
  57. 57. hospitals
  58. 58. physicians
  59. 59. NO
  60. 60. Adjusting your MLR labels so that you get payment for health care costs that then fund your quality programs Marrying qualitative goals with quantitative goals Providers and health plans influencing each other’s star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeezeit’srelative them out? Tying your satisfaction surveys to CAHPS surveys – using the same language in your in-house surveys to groom your members for positive feedback and helpful mock results Whether or not to absorb the member’s co-pay if that prevents them from getting care and providing risk adjustment opportunities
  61. 61. Adjusting your MLR labels so that you get payment for health care costs that then fund your quality programs Marrying qualitative goals with quantitative goals Providers and health plans influencing each other’s star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeezeit’srelative them out? Tying your satisfaction surveys to CAHPS surveys – using the same language in your in-house surveys to groom your members for positive feedback and helpful mock results Whether or not to absorb the member’s co-pay if that prevents them from getting care and providing risk adjustment opportunities
  62. 62. If we haven’t provided you with EXCELLENT SERVICE today, please tell the manager
  63. 63. If we haven’t provided you with EXCELLENT SERVICE today, please tell the manager because his bonusdepends on your survey answers
  64. 64. Adjusting your MLR labels so that you get payment for health care costs that then fund your quality programs Marrying qualitative goals with quantitative goals Providers and health plans influencing each other’s star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeezeit’srelative them out? Tying your satisfaction surveys to CAHPS surveys – using the same language in your in-house surveys to groom your members for positive feedback and helpful mock results Whether or not to absorb the member’s co-pay if that prevents them from getting care and providing risk adjustment opportunities
  65. 65. Adjusting your MLR labels so that you get payment for health care costs that then fund your quality programs Marrying qualitative goals with quantitative goals Providers and health plans influencing each other’s star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeezeit’srelative them out? Tying your satisfaction surveys to CAHPS surveys – using the same language in your in-house surveys to groom your members for positive feedback and helpful mock results Whether or not to absorb the member’s co-pay if that prevents them from getting care and providing risk adjustment opportunities
  66. 66. Adjusting your MLR labels so that you get payment for health care costs that then fund your quality programs Marrying qualitative goals with quantitative goals Providers and health plans influencing each other’s star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeezeit’srelative them out? Tying your satisfaction surveys to CAHPS surveys – using the same language in your in-house surveys to groom your members for positive feedback and helpful mock results Whether or not to absorb the member’s co-pay if that prevents them from getting care and providing risk adjustment opportunities
  67. 67. alignment
  68. 68. engage
  69. 69. it’snotjustaboutdata
  70. 70. it’saboutthepatient
  71. 71. If this talk hasn’t provided you with some EXCELLENT IDEAS, please let me know
  72. 72. Thank you! wpan@ppmsi.comWWW.SNOOPY.COM

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