Outsourcing Star Improvement. Krista Sultan RN, BSN, MS. Program Development Manager

Transcription

1 Outsourcing Star Improvement Krista Sultan RN, BSN, MS Program Development Manager

2 The Evolution of Pay for Performance The Affordable Care Act Ties Quality to Reimbursement Medicare Advantage Plans are given Star Ratings to denote level of quality Quality Standards for bonus payments are raised each year

3 Regulations and Bonus Payments The Affordable Care Act originally tied Quality ratings to bonus payments Plans must score 4 or 5 stars to qualify The CMS Demonstration Project extended the bonus payment structure to award bonus payments to plans with average ratings Plans with 3 stars now qualified for bonus payments CMS Demonstration Project has been subject to much scrutiny for awarding average performance. These bonus payments will end in 2014.

4 From Ratings to Reimbursement Quality Bonus Payment (QBP) by Star Rating Year 2.5 stars 3.0 stars 3.5 stars 4.0 stars 4.5 stars 5.0 stars % 3.0% 3.5% 4.0% 4.0% 5.0% % 3.0% 3.5% 4.0% 4.0% 5.0% % 3.0% 3.5% 5.0% 5.0% 5.0% % 0.0% 0.0% 5.0% 5.0% 5.0% Rebate Percentage by Star Rating Year 2.5 stars 3.0 stars 3.5 stars 4.0 stars 4.5 stars 5.0 stars % 66.7% 71.7% 71.7% 73.3% 73.3% % 58.3% 68.3% 68.3% 71.7% 71.7% % 50.0% 65.0% 65.0% 70.0% 70.0%

5 5 Star Plans Star Ratings-A Visible Measure of Quality 5 rating clearly displayed on CMS website 5 plans can enroll patients year round 5 plans have the lowest rate of plan attrition despite competition from lower cost plans. CMS mails letters to patients in low rated plans and actively encourages them to enroll in another plan. Low rated plans cannot enroll patients online 2 plans lose 22% members annually Low Performer Icon Low Rated Plans (2.5 or )

6 Penalties for Low Ratings Beginning in 2015 CMS can eliminate plans with 3 stars or less! Low rated plans have significantly lower overall enrollment Low rated plans do not receive rebates for bidding under the maximum allowable plan cost The cost of running the plan is prohibitive without bonus payments May adversely effect opportunities at the legal organizational level for: Expanding service area Increasing product offerings Obtaining new contracts

7 Star Ratings Correlate to Plan Attrition

8 Star Ratings Map to Patient Satisfaction

9 Calculating Quality Data is complied from a number of different sources to calculate star ratings. Patient Surveys CMS Administrative Data

10 Heavy Weight Measures Heavy Weight Measures are given a weight 3x greater than process measures. Outcome Measures Improving/Maintaining Physical Health Improving/Maintaining Mental Health Intermediate Outcome Measures Controlling Blood Pressure Taking Cholesterol Medication as Directed

11 EZ Analytics Stars Reporting Specific Metric Analysis Simple Reports with One Click Overall Performance Snapshot 11

12 Medicare Star Ratings Improvement Program The Citra Star Ratings Program is a complementary payer solution created to use the Patient Advocate service platform infrastructure to improve a plan s star ratings through data-driven high-touch service designed to improve member experience and keep members healthy. The emerging exchange market has already impacted Medicare Advantage payers. Consumers use star ratings to comparison shop plans. Unsatisfied consumers are allowed to switch to a 5-Star plan at anytime.

13 Program Modules Patient outreach with proven scripting and workflow technology to schedule care gaps Patient profiles and preferences recorded to enhance gap closure success rates On-going communication with physicians to alert of potential compliance or medical cost risks Completion of Rx reconciliation to identify and offer solutions for Rx compliance and adherence On-going reporting to help plans with CMS compliance

14 Capturing Patient Engagement Intelligent Outreach Patient Advocates call from the physician s office or on behalf of the physician Patient Advocates function as an extension of the physician office Personal Touches Patient preference data is recorded to customize care Personalized call greetings Experience with Success Touch rates up to 75% higher than average call center Seamlessly link communication across the care team continuum

15 Technology-Driven Workflow Orange Patient Advocates login and easily confirm identity and ensure HIPAA requirements are met. The platform prompts the Patient Advocate to follow-up on an outstanding issue, e.g. annual wellness visit, Rx adherence, post-acute care, clinic, etc. The Patient Advocate communicates with the patient to close the flagged care gap and schedules a PCP appointment.

16 Technology-Driven Workflow Smart prompt fields capture PCP culture reminders to ensure the patient feels the experience of their PCP. Patient Advocates are prompted to closeout their work queue instance and all activity is tracked. The process repeats for both inbound and outbound outreach.

17 Quality Assurance Constant quality monitoring ensures accuracy and courtesy Call data is constantly analyzed to maximize staffing according to reach rates and population attributes Call recordings are linked to touchpoints for quality assurance, accountability and process improvement Contact Center leadership engaged with physician partners and nonclinical leadership Quality plan metrics prioritize patient satisfaction

18 The Service Difference Service environment adopts the culture of implementing practice group Integrate Medical Cost, Quality and Patient experience programs in a common platform Global view of data makes it easy to measure program effectiveness and improvements Rapid deployment of new services

19 Star Ratings Improvement Results Summary of Citra Health Solutions Outreach (7/14/13-12/1/13) Total Calls Made 85,088 Unique Patients Called 31,516 Unique Patients Reached 8,321 Reach Rate 26.40% Appointments Made 1,672 Records Received 1,019 Star Care Gaps Closed 70,592 Partner plans saw an increase of 0.5 to 1.0 Stars in Ratings This equates to between 3-3.5% bonus payment for

20 High Touch Yields High Ratings Measure Adult BMI Assessment Breast Cancer Screening Cardiovascular Care: Cholesterol Screening Colorectal Cancer Screening Diabetes Care: Cholesterol Screening Closure Rate July 2013 Part C Domain 1: Staying Healthy Star Rating July 2013 Closure Rate December % 55.4% 56.4% 69.2% Star Rating December % 90.5% 33.7% 51.3% 65.8% 87.7% Glaucoma Testing 49.8% 63.4%

21 Questions?