By Beth Friedman, Sr. Partner, FINN Partners
It has been said that wherever Medicare goes, so do all the rest of the payers. If last week’s RISE National 2023 keynote speaker was any indication, future efforts and investments by payers and health plans will focus on three specific areas: compliance, data collaboration, and member engagement.
Christi A. Grimm, Inspector General, Office of Inspector General (OIG), at U.S. Department of Health and Human Services (HHS) opened the annual RISE National event with a stark report on the prevalence of fraud within the Medicare Advantage (MA) program. She emphasized the importance of risk adjustment to Medicare’s success, but also exposed serious issues related to overcoding (diagnosis codes without corresponding treatment) and codes assigned during in-home assessments that lacked a similar diagnosis from other healthcare providers.
The OIG’s powerful use of data to identify these MA red flags is representative of how other health plans and payers optimize the healthcare data they curate, collate and analyze. I spoke with six industry experts during RISE National to better understand how health plans and payers use data to improve performance. Here’s what they had to say.
1. Build Stronger Engagement with Medicaid and Dual Eligible Beneficiaries
Mikal Sutton, Managing Director, Medicaid Policy at Blue Cross Blue Shield Association, reiterated the urgent need for Medicaid redeterminations in 2023 during an opening panel session dedicated to upcoming regulatory changes. In the wake of a Public Health Emergency wind down, 15M Medicaid enrollees will potentially lose healthcare coverage.
However, only one-third of managed care plans have verified or current contact information for 76 to 100 percent of their Medicaid members according to a recent report published by the Kaiser Family Foundation. Two companies were targeting better Medicaid and dual eligible member data at RISE.
Dan McDonald, Founder and CEO, 86Borders
The lack of accurate contact information for Medicaid and dual eligible members is one of the biggest challenges health plans face. This hard-to-reach population requires the most help to address SDOH barriers and coordinate care for complex medical conditions. They’re often unreachable, underserved and pose significant financial risk to a health plan’s bottom line.
86Borders personally engages Medicaid and dual eligible members. The company has spent the past decade building technology platform and care coordination services to connect with the unreachable and underserved. McDonald provides three points of advice for Medicaid managed care organizations and other plans with Medicaid and D-SNP populations.
- Work tirelessly to ensure contact information is correct and properly updated.
- Establish a trusted member relationship through one-to-one connections. Mass messaging doesn’t work for this population.
- Go beyond traditional healthcare issues such as appointment scheduling to address everyday challenges and barriers including housing, transportation and food.
Jonathan Wiik, Vice President, Healthcare Insights, FinThrive
Wiik reiterated the need for better data hygiene across Medicaid beneficiaries. Wiik predicts gaps in care and spikes in costs if proper redeterminations are not quickly conducted—even beginning as early as April 1, 2023.
Such insights as neighborhood safety, transportation challenges (household access to a car), and living situations (living alone or with multiple family members) must come together with clinical data to help health plans improve members’ lives and mitigate risks. Surveys aren’t always accurate. And these high-risk members don’t usually trust health plan screenings or assessments. Additional steps are necessary. To improve data regarding Medicaid members Wiik encourages plans to:
- Educate internal teams on the need for redeterminations
- Identify and update information for each and every Medicaid member in your plan
- Determine accurate primary and secondary insurance coverage starting next month
- Integrate consumer data sources with encounter information
- Reconnect with members as soon as possible
- Provide members with resources and support
2. Fine-Tune Data Exchange to Enhance Payer-Provider Collaboration and Workflow
An entire track at RISE National was dedicated to improving payer-provider collaboration with a focus on workflows, interoperability and AI. I witnessed true progress toward identifying and eliminating redundant tasks through better data sharing and exchange, often viewed skeptically by healthcare providers. Working smarter, not harder, on both sides of the healthcare ecosystem is a win-win goal. Here is one example.
Thirumalai Rajagopai (Raj), Senior Vice President, Payer Solutions, MRO
All health plans struggle with gaining quality provider data to support mandated quality measures reporting. This is especially true for data trapped within independent physician practice systems and ambulatory clinics. And while EHRs have thousands of data elements, not every piece of data impacts quality measures or is needed by the health plan.
Digitizing and exchanging only what a health plan needs (versus all patient data available) is one way MRO, a company focused on accelerating the exchange of clinical data, is saving time and money for providers and payers. The company curates only the exact data elements a payer needs. This additional step in payer-provider data exchange makes the most of available provider data, reduces laborious communications for claims and other needs, and decreases the administrative burden for both teams.
Raj provides one consideration for organizations increasing their data exchange capabilities. “Verify that your vendors are using best practices and industry standards to ensure clinical intent and data integrity are maintained and compliance is assured throughout the data processing and curation cycles.” MRO recently achieved NCQA’s Data Aggregator Validation (DAV) designation for diligence in maintaining data integrity throughout payer-provider data exchange.
Mayur Yermaneni, EVP Strategy, Innovation and Growth, AssureCare
Workflows at the point of care were also discussed during RISE National. Intelligent clinical workflows should know what data make the most impact for which cases. Data must be collected and segmented behind the scenes, then presented to the clinician within holistic workflows using connected care platforms.
According to Yermaneni, data sources should encompass every aspect of the patient journey including pharmacies, ambulatory clinics and even health plan interactions. Armed with the complete patient story, clinicians can make the most of every patient visit to save time and ensure a comprehensive encounter.
3. Build Stronger Compliance Programs and Ensure Data Quality
According to Grimm, stronger OIG oversight is ahead for Medicare Advantage plans, and wrongdoers will be held accountable. During her keynote session, Grimm mentioned that 69 percent of MA payments lacked support for diagnosis used to calculate risk adjustment. “I’m here to underscore my commitment to ensure MA and plans effectively combat fraud, waste and abuse,” Grimm said. “It’s one of my top priorities. It should be a top priority of yours as well.”
To fight sophisticated and easily replicable fraud schemes, Grimm recommends every health plan bolster their internal compliance programs. She adamantly stated that “healthy compliance is good business.” Several vendors reiterated the connection between data integrity, quality and compliance.
Mike Noshay, Chief Strategy Officer, Verinovum
Data quality for MA plans is a top priority for Verinovum. The company is a trusted and secure vendor for data curation and enrichment with HITRUST CSF certification, AICPA SOC certification, and NCQA DAV validation. According to Noshay, “Interoperability without data quality is ineffective” and “quality improvement programs including STAR ratings, MIPs, and other clinical quality measures struggle when data is inaccurate, duplicative or delayed.”
The demand for actionable clinical data has never been greater. At this point in the quality journey all eyes are focused on data quality, integrity and hygiene.
Stephanie Broderick, EVP Strategic Initiatives, Clinical Architecture
“Data quality isn’t just a health plan priority, it is a nonnegotiable requirement for everyone across the healthcare ecosystem,” said Broderick, a 28-year healthcare data veteran. Broderick’s work at Clinical Architecture includes strategic partnerships with some of the nation’s largest health systems and the Centers for Disease Control (CDC), as discussed in the company’s most recent podcast.
Success with population health, health information exchange (HIE), quality reporting and value-based care has always driven the need for data quality, according to Broderick, “but emerging regulatory changes including those mentioned above are pushing the envelope on data quality and usability more than ever.”
Keeping an Eye Forward for All
Services such as those provided by the companies mentioned above will be increasingly important to make high quality patient data exchange a reality across all segments of healthcare. It was inspiring to see how the troves of health data now available to providers, plans and payers are being curated to support innovative and valuable quality program to accomplish healthcare’s most important goals: better patient outcomes, higher levels of care quality, and reduced healthcare costs.
I look forward to attending RISENational2024 March 17-19 in Nashville. See you there!