Cambria Releases White Paper: Health Care Reform & Star Ratings for Health Plans: How to Manage Through the Murkiness of Medicare’s New Realities

---Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals, Managing Partner at Quo Magis Partners

The entire white paper can be downloaded at the following link:  http://www.sharedhealthdecisions.com/5273/5294.html   This excerpt highlights the “5 Essential Pillars for Success” for Medicare Advantage plans. 

The Five Essential Pillars

Any team can only cope with what they understand.  Breaking the Star Ratings program down into bite-size pieces will make tackling these components more achievable so that challenges can be overcome and measure results maximized.   A manager should delegate specific goals to specific team members, so that no one person must manage it all.  In our estimation, there are five principals that can be applied to this effort.   Without any one of the following components in a fully operational state, a plan cannot hope to improve its rating: 

1.    Cohesive Team Pulling in the Same Direction

·         Plan executives must clearly state the goals, designate team members at all levels of the operation, in every department.  

·         Results should be part of the team and individual incentive /merit program.

·         Redundancy of critical functions should be built into the team, to plan for potential staff attrition in critical places.  An understudy will always be in place and ready for a chance “at bat”.    

2.     Communication-Up, Down, Sideways

·         Tracking results and targets requires careful and consistent communication of initiatives. 

·         In addition to routine meetings, email blasts, and conferences, the program or star manager must be willing to nudge already overworked colleagues to meet milestones and deadlines.

·         Communication requires careful listening to members, providers, technologists, and managers.  Sometimes the challenge itself has been misidentified, requiring a shift in strategy.  Without careful listening, the team could plow on in the wrong direction and completely miss the mark. 

3.    Access to Data- Timely & Accurate

·         Because there are a number of places where data is imported, cross- walked, converted, transferred to vendors or auditors, and later to CMS, any dropped or misaligned data could cost the plan meaningful points on the numerator or denominator.   

·         Processes to assure that the data is complete and accurate from the claims systems, which validate what is supplied to CMS, should be executed at least monthly to confirm the current state. This will also allow managers to tackle the measures which will have the greatest impact or which represent low hanging fruit for achieving results. 

·         Managers and Star Team Members need ready-access to that data so that they can troubleshoot problems or success early.

·         Instill in the team a little dose of “data skepticism” such that they don’t just accept results that “don’t look right”.  Waiting to identify a data process problem may result in a lack of time to act. 

4.    A Means to Navigate:  Technology/ Software

·         Access to data is not enough without a means to manage it.  The executive has a need to identify which providers are helping or hurting; which measures are lagging or improving; which team members are achieving results (or not).  

·         By identifying the challenges, managers can assign the most adept teams to focus on results at the provider, member, data or campaign level.   

·         Software that can capture the data, identify the priorities, and assign the resources to resolving them is an essential tool in achieving results, when implemented into Standard Operating Procedures.  Without such software, a team must rely upon many manual processes that could be costly to manage, with key tasks subject to “slipping through the cracks”.

5.    A Roadmap:  “Hope is NOT a good strategy”

·         Once a plan manager knows where the results lie, and where the gaps are, there is a need for the team to know what to do about it and how to do it.

·         The Roadmaps or “Campaigns” that a plan constructs to address specific measures should identify a strategy for pursuit of the mathematical result, incorporating tactics that may involve the provider community, the staff outreach department or the member himself. 

These campaigns imply an action-orientation whereby one is not just looking at the data, but is deploying resources under a specific program to achieve named and documented targets, perhaps over a short period, or over the whole year. 

More information regarding Valiant Health’s ProActive® Management technology can be found at www.valianthealth.com.

Terri is the founder of Cambria Health Advisory Professionals, and a Managing Partner at Quo Magis Partners. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders, a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional 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 her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.