“It’s essential to accelerate the speed and time for gaps to identify them faster and proactively.”

In the context of risk adjustment gaps, there are two overarching goals—to identify and accurately predict member conditions. To do this, health plans are reliant on the amount and quality of the data they have—primarily sourced from clinical and claims data. Plans need this data to produce intelligence and directives to providers on how best to proceed on a proactive care path. 

Due to COVID, plans experienced a decrease in access to data and that resulted in unique challenges for risk adjustment and their ability to supply predictive analytic recommendations to providers. As we return to normalcy, plans can expect a huge influx of data in 2022 and 2023 as members return to their normal care and procedures. This is going to be great for generating greater intelligence and actionable insights, but it’s also going to present some unique challenges and strain on some plan’s operational systems, especially if they’re manual. 

For plans who have the technology and capacity to process large amounts of data, these coming years may be very fruitful for risk adjustment. The large data sets will provide a lot of intelligence for predicting member gaps and creating strong member segmentation models.

About Our Guest: Abe Chaaya is the Managing Director of Product Management for Analytics Products. Abe has over twenty years of experience as a global IT leader in QA, DevOps, and product management spanning several industries including manufacturing, payment systems, and healthcare IT. He holds a bachelor's degree in mechanical engineering from Rensselaer and an MBA in operations and technology from Bentley. 

“There’s a whole new range of possibilities for interacting with members through digital medium.”

Marketing and communications in the Medicare Advantage space have evolved significantly in the past five years. Leaving behind a one-size-fits-all outreach approach, today’s best practice is messaging for a journey of one—targeting unique individuals or groups of individuals with similar needs. For example, health plans would want to communicate differently with members who have chronic conditions versus healthy members. Deploying specific-to-the-member messaging engages the member, grabs their attention, serves them up with relevant information, and guides them through a progression of messaging including calls to action. 

Messages are deployed via a number of digital channels such as email campaigns, social media, and newsfeed ads. Make note, that the depth of modern-era outreach is expanding rapidly to include cutting-edge technologies such as artificial intelligence voice technology bots and care robots. 

It’s important to remember that all of these digital tactics are not just forms of communication flowing back and forth. It’s a form of optimizing and understanding the communications. Most digital interactions leave a trail of data that can be analyzed with machine learning and artificial intelligence tools. 

What that means ultimately, the member journey with the plan and with their own health no longer needs to be an isolated journey. The member’s health trajectory with the plan can be smooth, seamless, and guided by the hand of these digital tactics and insights. 

 About Our Guest: Andrea Wallace (Dre) has a background in product development and is an innovator in solutions for healthcare organizations. Wallace has served in a variety of roles across the technology industry as an innovator, investor, and strategist. She is the recipient of the 2019 Nolan Groce Business Leadership Award for her work in the startup and entrepreneurial ecosystems.

Resources:
Tech Adoption Climbs Among Older Adults. Monica Anderson, Andrew Perrin. May 17, 2017. https://www.pewresearch.org/internet/2017/05/17/technology-use-among-seniors/

"The only way to proactively identify and manage members with rising risk is by connecting care teams with real time data, analytics, and predictive models."

In this episode, we explore the origins of care management, reactive versus proactive models of care, ways to coordinate care with real-time data, practical uses for data and analytics for diagnosis and treatment, as well as the ideal care management dashboards for frontline healthcare workers, managers, and directors of care management programs.

Guest : Dr. Chris Johnson is the Care Management Product Lead, designing and implementing health management solutions for government-sponsored health plans. Building upon academic training in medicine, public health, and medical informatics, Dr. Johnson pioneered new workflow methods at companies such as Dignity Health, Zynx Health, and Adventist Health. Dr. Johnson now leads a growing team to create effective solutions for health payers and provider networks.

Resources:
Baclic, O., Tunis, M., Young, K., Doan, C, Swerdfeger, H., Schonfeld, J. (2020). Challenges and opportunities for public health made possible by advances in natural language processing. Canada Communicable Disease Report, 46(6): 161-168. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7343054/ 

“Maintain the spirit of continual improvement across the organization. Even though there is uncertainty, CMS rewards heavily for improvement year over year.”
 
2021 was the first year that CMS shifted away from clinical metrics and skewed the weight towards member experience. Health plans will need to address matters such as how well members understand their benefits, the ease of the experience surrounding the use of benefits, and resolution of issues with paying for services—to name a few examples. Member experience is the summation of the entire scope of interactions for a member with their health plan and providers. We're talking with Erica Krieger about what plans can do in 2022 to boost Star Ratings.

Guest: Erica Krieger is the Vice President of Quality, a front runner in the Medicare Advantage plan operation space. Krieger has more than 20 years of experience—spanning strategic informatics, management of Star program reporting, HEDIS operations, forecasting models for HEDIS improvement initiatives and scoring methodologies.

Resources
Age of MA plans plays role in success:  (2021). Fact Sheet - 2021 Part C and D Star Ratings. https://www.cms.gov/files/document/ 2021starratingsfactsheet-10-08-2020.pdf 

By 2030, the entire baby boomer generation will be older than 65:  (2018, March 13. Revised 2019, Oct 8). Older people projected to outnumber children for first time in U.S. history. https://www.census.gov/newsroom/press-releases/2018/cb18-41- population-projections.html 

Season 1 is coming soon! 

Join us for insider insights and perspectives for healthcare executives of government-sponsored health plans. We’re talking to the experts about the unique operating infrastructure necessary for profitability and providing a best-in-class member experience. Topics include technology, data security, operations, health management, member engagement, risk adjustment, quality measures, start-up and growth tactics, legal and regulatory.