Posts Tagged ‘health plans’

6 Health Plan Trends in Remote Patient Monitoring

February 12th, 2015 by Patricia Donovan

CHF and COPD are the health conditions most frequently targeted by health plan remote monitoring programs.

Frequent emergency room users, individuals with chronic comorbidities and members recently discharged from the hospital are the populations most often monitored remotely by health plans, according to 2014 market data.

Payors comprised 16 percent of respondents to the Healthcare Intelligence Network’s 2014 survey on remote patient monitoring.

The survey identified the following payor trends in remote care management:

  • Forty percent of health plans said they had a remote monitoring program in place, versus a high of 64 percent for case management and a low of 24 percent for hospital/health systems.
  • Health plans principally rely on case management assessments to identify remote monitoring candidates (80 percent) a fraction more than case management organizations themselves (78 percent). They were also most likely to depend upon direct member/patient referrals—a high of 44 percent versus a low of 0 percent for health plans and a median of 25 percent for hospital/health systems.
  • Health plans were most likely to monitor frequent hospital/ER utilizers remotely (100 percent) versus a low of 55 percent for case management and a median of 75 percent for hospital/health systems. They were also most likely to monitor those patients recently discharged (80 percent) versus a low of 44 percent for case management and a median of 50 percent for hospital/health systems.
  • Of the top five chronic diseases monitored by remote technologies (CHF, COPD, asthma, hypertension, and stroke), health plans were most likely to monitor CHF (100 percent versus a low of 25 percent for hospital/health systems and a median of 89 percent for case management); COPD (100 percent versus a low of 50 percent for hospital/health systems and a median of 67 percent for case management); and asthma (80 percent versus a low of 44 percent for case management and a median of 50 percent for hospital/health systems.
  • In terms of payor challenges associated with remote monitoring, patient education was a strong concern (60 percent) versus a low of 25 percent for hospitals/health systems and a median of 56 percent for case management, as was reliability of self-reported data (60 percent) versus a low of 25 percent for hospitals/health systems and a median of 44 percent for case management.
  • Across the board, all three sectors (100 percent) said telephonic case management was key to remote monitoring.

Source: 2014 Healthcare Benchmarks: Remote Patient Monitoring

Infographic: How Certified Case Managers Navigate the Healthcare Landscape

March 17th, 2014 by Jackie Lyons

Board-certified case managers (CCMs) work in a variety of healthcare settings. The top three are hospitals (24 percent), worker’s compensation organizations (18 percent) and health plans (17 percent), according to a new infographic from the Commission for Case Management Certification (CCMC) and Health2 Resources.

This infographic also illustrates the roles of CCMs, the content and value of their knowledge, where CCMs are located in the United States and more.

You may also be interested in this related resource: 2013 Healthcare Benchmarks: Case Management. This 78-page resource provides actionable information from 118 healthcare organizations on the prominence, placement and responsibilities of case managers as well as case management-driven outcomes in healthcare utilization, cost and compliance.


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Which CMS 5-Star Quality Domains Are Best Candidates for Improvement?

March 5th, 2014 by Jessica Fornarotto

CMS Five-Star Rating

With an additional star in CMS Five-Star Quality Ratings System worth about $50 per member per month (PMPM), according to L.E.K. Consulting (when moving from a three- to four-star Medicare Advantage plan), health plans are anxious to fine-tune operational processes and improve their rankings. Joseph Johnson, vice president of L.E.K. Consulting, shares which of CMS’ Five-Star Rating categories could be improved.

There is some data that indicates that certain CMS Five-Star Ratings domains or categories are better candidates for improvement than others. All Medicare Advantage (MA) plans score similarly to the top 10 MA contracts, and perform better on measures directly under their control — particularly member experiences with health plans, member complaints and appeals, and customer service.

Given the relative underperformance of measures in managing chronic conditions, we believe this is an area ripe for innovation and improvement from prioritization initiatives. CMS has recognized the opportunity to further improve the measures under ‘managing chronic conditions’ and has increased its emphasis by weighting these measures more heavily relative to other domain areas.

Now I’d like to discuss how to best identify CMS Five-Star Quality Rating improvement initiatives in a rigorous and systematic manner, by looking at sample data from the performance of an HMO MA product, with thresholds for the three-, four- and five-star scores. Within a given CMS Five-Star Quality Rating measure, individual members or provider segments are seen within a given MA contract.

When looking at which providers do well, which ones see a large base of membership, and also more importantly, the measures where skew may exist across the member-provider segments or cohorts, the end goal is to drive overall performance to the next threshold. Diabetes/cholesterol control and diabetes eye exams are seen as potential good member and provider cohorts to focus on for targeted improvement opportunities. This approach lays the foundation for how to prioritize targeted star improvement efforts.

Excerpted from: A Strategic, Best Practice Approach to Improve CMS Star Quality Ratings, a 45-minute webinar

3 2014 Trends for Health Plans

January 21st, 2014 by Jessica Fornarotto

Influencing primary care, aggregating and mining data, and embracing bundled or episode-based payments are three trends that will influence health plans in 2014, predicts Catherine Sreckovich, managing director in the healthcare practice at Navigant Consulting.

HIN interviewed Sreckovich on these trends prior to her presentation during HIN’s tenth annual webinar on Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.

HIN: Where will data analytics take health plans in the coming year, and how will this shape population health management offerings?

(Catherine Sreckovich): We’re certainly hearing a lot about big data, and it will be an integral approach to merging this practice’s or population’s health, the ability to aggregate and mine data is going to be an essential capability for health plans for their predictive models. And the outputs of these models are going to enable the health plans to identify and stratify their members or population health. Member and patient demographics can also inform consumer engagement strategies to support population health. And the analytics are going to inform the effectiveness of different care management interventions and consumer engagement strategies.

HIN: Health plan case managers embedded alongside providers has become almost a de facto model. How will payors influence primary care delivery in the year to come?

(Catherine Sreckovich): There is a number of approaches evolving right now and that will continue to evolve as payors attempt to influence primary care delivery. One is the use of patient-centered medical homes (PCMHs) and other integrated models to expand the payor’s role as the primary care case manager.

In addition to paying primary care providers to hire case managers and care coordinators, payors are pushing for shared savings arrangements with these primary care providers, such as within an accountable care organization (ACO), and to push them to manage the care for those with chronic conditions.

We’re also seeing payors paying for primary care physicians to become certified PCMHs and to implement electronic health records (EHRs), either by paying directly for the certification of the technology or by adding bonus payments to their FFS rates.

Payors are also paying for incentives for primary care physicians to offer wellness programs such as smoking cessation or weight loss programs and are trying very hard to influence where and to whom primary care physicians refer their patients by giving them information about the cost and quality of other provider types, such as specialists and hospitals.

And we will continue to see that payors will target the larger primary care physician practices with whom they have a critical mass of members to achieve enough savings to offset the added costs of incentives, bonuses and shared savings arrangements. As a result, we expect that some of the smaller primary care practices will likely not receive the same level of support and push from payors.

In another example, we see payors increasingly partnering with non-traditional providers, such as retail-based clinics and community health centers to offer easily accessible primary care at lower costs. And this will certainly be an opportunity to address some of the physician supply shortages that we anticipate seeing in the next year or so as more and more people have access to healthcare insurance and coverage.

Finally, another approach payors are using is to offer members access to virtual doctor visits via webcam, for example, and other telemedicine approaches that are giving individuals access to these primary care providers to increase access to convenient and low cost primary care for their patients.

HIN: CMS and top-performing Pioneer ACOs are heavily invested in bundled or episode-based payments. Will more private payors embrace this reimbursement method as well?

(Catherine Sreckovich): Definitely. The bundled or episodic-based payment approaches are here to stay. We’re starting to see this take off in a number of states. For example, there are state innovation grants that CMS has provided to states like Arkansas, Ohio, Delaware and others looking for opportunities to implement multi-payor bundled payment initiatives. Although these are not necessarily the traditional ACO model, they built off of that ACO model.

We also see that the large health plans in various states are starting to build and develop ACOs. Key to these are the shared savings arrangements that they’re implementing with these payment approaches. So whether they’re bundled or episodic-based payments or whether they look more like a traditional ACO, if there is such a thing, we’re starting to see takeoffs on those kinds of models as payors and health plans become more creative in the development of their alternatives.

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry