Medicare Revenue Management • The Reach Resort, Key West • January 18, 2012

QualityRiskIntegrating

Risk andQualityBenefits of this Critical Merger

Wayne Pan, MD, MBAChief Medical OfficerPacific Partners Management Services, Inc.

?

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 squeeze 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

MLR: medical loss ratio

medical expensespremiums collected

MLR: medical loss ratio

medical expensespremiums collected

admin expensespremiums collected+ = 1

MLR: medical loss ratio

medical expensespremiums collected

admin expensespremiums collected+ = 1

Limits premiums: 118% of medical losses (85%)125% of medical losses (80%)

INNOVATION?

MLR: medical loss ratio

medical expensespremiums collected

admin expensespremiums collected+ = 1

admin expenses: admin ratio

+profit margin

MLR: medical loss ratio

medical expensespremiums collected

admin expensespremiums collected+ = 1

medical expenses: incurred claims

expenditure+

“activities that improvehealthcare quality”

make patients sicker?

get sicker patients?

quality:case management/care coordination

chronic disease managementmedication/care plan compliance

reduction of disparitiesquality reporting/documentation

accreditation fees directly related to qualityhospital readmission prevention/discharge planning

patient education and counselingpromotion of patient safety and error reduction

prospective drug utilization reviewwellness and health promotion programs

wellness assessments/coachingrewards to members

the argument for quality

qualitymean you?2What does

measurement?improvement?

startwithwhy

whysmen

whysmen5

whywhywhywhywhy

patient

beginsandends

patient

adapted from Simon Sinek, “Start with Why,” (2009)

why

how

what

process

program

patient

from inside out

think

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 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 squeeze 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 squeeze 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

QualityRisk

weare

here

from: missclaudiawong.blogspot.com (January 30, 2011)

4x4 healthcare

4processes

4dimensionaldata

x

PCPs

Specialists

Patients

CaseManagers

anticipation collaboration

communication

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 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 squeeze 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 squeeze 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

networkconsiderations

networkmanagement

behaviorchange

put hot triggers in the path of

motivated peopleBJ Fogg, PhD

Director, Persuasive Technology LabStanford University

incentivealignment

incentivetiming

Have you seenANSWERS?

6-month old lab mixwell-trained to doold tricks, not so

good with new tricks

healthplans

healthcareproviders

hospitals

physicians

NO

it’s����������� ������������������  relative

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 squeeze 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

it’s����������� ������������������  relative

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 squeeze 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 withEXCELLENT SERVICEtoday, please tell the

manager

If we haven’t provided you withEXCELLENT SERVICEtoday, please tell the

managerbecause his bonus

depends on your survey answers

it’s����������� ������������������  relative

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 squeeze 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

it’s����������� ������������������  relative

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 squeeze 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

it’s����������� ������������������  relative

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 squeeze 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’snotjustabout data

it’saboutthepatient

If this talk hasn’t provided you with some

EXCELLENT IDEAS,please let me know

wpan@ppmsi.com

Thank you!

WWW.SNOOPY.COM