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Integrating risk and quality 18 jan12
 

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

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 Integrating risk and quality 18 jan12 Presentation Transcript

    • 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
    • ?
    • 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
    • MLR: medical loss ratio medical expenses premiums collected
    • MLR: medical loss ratiomedical expenses admin expensespremiums collected + premiums collected = 1
    • MLR: medical loss ratiomedical expenses admin expensespremiums collected + premiums collected = 1
    • Limits premiums: 118% of medical losses (85%) 125% of medical losses (80%)
    • INNOVATION?
    • MLR: medical loss ratiomedical expenses admin expensespremiums collected + premiums collected = 1
    • admin expenses: admin ratio + profit margin
    • MLR: medical loss ratiomedical expenses admin expensespremiums collected + premiums collected = 1
    • medical expenses: incurred claims expenditure +“activities that improve healthcare quality”
    • make patients sicker?
    • get sicker patients?
    • 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
    • the argument for quality
    • What does 2qualitymean you?
    • measurement?improvement?
    • startwithwhy
    • whysmen
    • 5 whysmen
    • whywhywhywhywhy
    • patient
    • beginsandends
    • patient
    • think what program fro m in si de how process ou t why patient adapted from Simon Sinek, “Start with Why,” (2009)
    • patientcenteredness
    • “how will the patient benefit from this?”“does this make it easier for the patient?”
    • 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
    • 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
    • Risk lity Qua
    • we are herefrom: missclaudiawong.blogspot.com (January 30, 2011)
    • 4x4 healthcare
    • 4processes x4dimensionaldata
    • communicationanticipation collaboration Case Managers Patients PCPs Specialists coordination
    • qualityprocess
    • riskadjustmentprocess
    • patient doctor documentation
    • patient doctor documentation same
    • quality: CMS 5 STARrisk adjustment: HCC
    • $$$$$$
    • revenuemanagement
    • whatabouttheexpensemanagement?
    • whataboutmedicalmanagement?
    • whataboutcarecoordination?
    • 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
    • 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
    • networkconsiderations
    • networkmanagement
    • behaviorchange
    • put hot triggers in the path ofmotivated people BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
    • incentivealignment
    • incentivetiming
    • Have you seen ANSWERS? 6-month old lab mix well-trained to do old tricks, not so good with new tricks
    • healthplans
    • healthcareproviders
    • hospitals
    • physicians
    • NO
    • 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
    • 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
    • If we haven’t provided you with EXCELLENT SERVICE today, please tell the manager
    • If we haven’t provided you with EXCELLENT SERVICE today, please tell the manager because his bonusdepends on your survey answers
    • 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
    • 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
    • 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
    • alignment
    • engage
    • it’snotjustaboutdata
    • it’saboutthepatient
    • If this talk hasn’t provided you with some EXCELLENT IDEAS, please let me know
    • Thank you! wpan@ppmsi.comWWW.SNOOPY.COM