Integrating risk and quality 18 jan12
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Medicare Revenue Management • The Reach Resort, Key West • January 18, 2012 Quality Risk Integrating Risk and Quality Benefits of this Critical Merger Wayne Pan, MD, MBA Chief Medical Officer Pacific Partners Management Services, Inc.
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Presentation given at Medicare Revenue Management meeting, The Reach Resort, Key West, January 18, 2012
Transcript of Integrating risk and quality 18 jan12
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
