---Terri Bernacchi, PharmD, MBA, Senior Partner, Valiant Health (www.valianthealth.com )
To succeed in an increasingly challenging reimbursement environment, Medicare Advantage plans must work in close collaboration with physicians to identify at-risk populations and facilitate interventions that that improve quality and lower cost. That is true for both the Part C & Part D portions of the program.
Some Medicare Advantage plans will thrive at the top of the quality ratings heap no matter what happens in the surrounding environment. Those plans have some common elements that give them a weighty advantage in terms of statistics and actual results. The common themes? Cooperative providers, clean data management processes, enabled clinical teams and executive leadership, and a clear, prioritized plan. In a phrase, they are able to exert maximal control over the variables that drive results which drive reimbursements.
Kaiser Permanente, for example, attributes its success to “a deep understanding of the star measures along with internal and external organizational processes and protocols”. They believe this has allowed the plan to achieve a Part D summary rating of 5 in 7 of the 8 regions.
Matt Nye, the vice president of Pharmacy Care Support Services, National Pharmacy Programs and Services of Kaiser Permanente spoke at the Academy of Managed Care Pharmacy’s spring meeting in San Diego in April 2013. His discussion included a brief company overview: coverage of 9 states and D.C. with 8.9 million members, 165,000 employees, 15,000 physicians, 36 hospitals and medical centers, and 1.05 million Medicare members. Nye noted that Kaiser’s program includes outpatient, inpatient, and ambulatory care pharmacies and services, home infusion, drug distribution, mail order and central fill operations, and centralized services.
Kaiser has some advantages in drug therapy management relating to its business model: it is an integrated practice model. He noted that they have placed an emphasis sharing accountability between physicians and pharmacists to ensure the appropriate use of medications.
Even if a plan does not have the benefit of “owning” the full scope of clinical, distributive, and practice infrastructure, the lessons learned from Kaiser can still be applied. Using technology and data management techniques, internal and organizational processes can be aligned to create common incentives and opportunities to maximize quality results to assure success in the current and future years.
Terri is a Senior Partner at Valiant Health, LLC, and founder of Cambria Health Advisory Professionals. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Valiant Health colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to IMS Health in late 2007. She has both a BS and a PharmD in Pharmacy and an MBA.
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