Integrating risk and quality 18 jan12
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Presentation given at Medicare Revenue Management meeting, The Reach Resort, Key West, January 18, 2012
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Integrating risk and quality 18 jan12
- 1. Integrating Risk Qua lity Risk and Quality BeneïŹts of this Critical Merger Wayne Pan, MD, MBA Chief Medical OfïŹcer PaciïŹc Partners Management Services, Inc. Medicare Revenue Management âą The Reach Resort, Key West âą January 18, 2012
- 7. ?
- 8. 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 inïŹuencing each otherâs 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 â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 9. MLR: medical loss ratio medical expenses premiums collected
- 10. MLR: medical loss ratio medical expenses admin expenses premiums collected + premiums collected = 1
- 11. MLR: medical loss ratio medical expenses admin expenses premiums collected + premiums collected = 1
- 12. Limits premiums: 118% of medical losses (85%) 125% of medical losses (80%)
- 13. INNOVATION?
- 14. MLR: medical loss ratio medical expenses admin expenses premiums collected + premiums collected = 1
- 15. admin expenses: admin ratio + proïŹt margin
- 16. MLR: medical loss ratio medical expenses admin expenses premiums collected + premiums collected = 1
- 17. medical expenses: incurred claims expenditure + âactivities that improve healthcare qualityâ
- 20. quality: case management/care coordination chronic disease management medication/care plan compliance reduction of disparities quality reporting/documentation accreditation fees directly related to quality hospital readmission prevention/discharge planning patient education and counseling promotion of patient safety and error reduction prospective drug utilization review wellness and health promotion programs wellness assessments/coaching rewards to members
- 21. the argument for quality
- 22. What does 2 qualitymean you?
- 24. startwithwhy
- 25. whysmen
- 26. 5 whysmen
- 28. patient
- 29. beginsandends
- 30. patient
- 31. think what program fro m in si de how process ou t why patient adapted from Simon Sinek, âStart with Why,â (2009)
- 33. âhow will the patient beneïŹt from this?â âdoes this make it easier for the patient?â
- 34. 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 inïŹuencing each otherâs 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 â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 35. 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 inïŹuencing each otherâs 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 â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 36. Risk lity Qua
- 37. we are here from: missclaudiawong.blogspot.com (January 30, 2011)
- 39. 4x4 healthcare
- 41. communication anticipation collaboration Case Managers Patients PCPs Specialists coordination
- 42. quality process
- 44. patient doctor documentation
- 45. patient doctor documentation same
- 46. quality: CMS 5 STAR risk adjustment: HCC
- 47. $$$$$$
- 53. 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 inïŹuencing each otherâs 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 â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 54. 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 inïŹuencing each otherâs 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 â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 58. behavior change
- 59. put hot triggers in the path of motivated people BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
- 62. incentive timing
- 63. Have you seen ANSWERS? 6-month old lab mix well-trained to do old tricks, not so good with new tricks
- 64. healthplans
- 66. hospitals
- 67. physicians
- 68. NO
- 70. 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 inïŹuencing each otherâs star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeeze itâsrelative them out? Tying your satisfaction surveys to CAHPS surveys â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 71. 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 inïŹuencing each otherâs star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeeze itâsrelative them out? Tying your satisfaction surveys to CAHPS surveys â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 73. If we havenât provided you with EXCELLENT SERVICE today, please tell the manager
- 74. If we havenât provided you with EXCELLENT SERVICE today, please tell the manager because his bonus depends on your survey answers
- 75. 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 inïŹuencing each otherâs star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeeze itâsrelative them out? Tying your satisfaction surveys to CAHPS surveys â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 76. 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 inïŹuencing each otherâs star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeeze itâsrelative them out? Tying your satisfaction surveys to CAHPS surveys â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 77. 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 inïŹuencing each otherâs star ratings: How high is high enough to lift up that poor performer and how low is low enough to squeeze itâsrelative them out? Tying your satisfaction surveys to CAHPS surveys â 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 memberâs co-pay if that prevents them from getting care and providing risk adjustment opportunities
- 79. alignment
- 80. engage
- 94. If this talk hasnât provided you with some EXCELLENT IDEAS, please let me know
- 95. Thank you! wpan@ppmsi.com WWW.SNOOPY.COM