Current Trends For Payers

Latest Episodes:

Shifting Measures In Stars—Making The Quick Pivot Oct 02, 2023

Show notes

This episode explores major changes to Medicare Advantage Star Ratings, including shifting measure weights, the removal of the Reward Factor, and the introduction of the Health Equity Index. Although some weights may return to previous levels, investments in customer service and digital platforms continue improving member experiences. Plans serving members with greater social risks may also benefit from performance-based incentives. Because the difference between four and five Stars can be narrow, success requires continuously analyzing data, measure weights, and resource allocation. Listen to gain practical insights into navigating Star Rating changes, identifying opportunities, and improving performance while keeping member outcomes at the center.

About Our Guest
Michelle Simon has over 15 years of experience in quality programs. She began her career on the commercial side with the quality rating system and transitioned into the Stars space where she has spent the majority of her career. Simon has a Masters degree in Organizational Leadership and a Post-Graduate Certificate in Healthcare Informatics and Data Analytics.

The Science of Predicting Member Conditions Sep 05, 2023

Show notes

As stewards of healthcare, health plans are responsible for managing the care of its members. This includes working with providers to capture member conditions accurately and comprehensively via medical charts and coding. This improves member outcomes and optimizes the plan's risk adjustment revenue which ultimately reduces member costs.
The scope of a prospective risk adjustment program is to account for historical member conditions, and identify and close gaps on suspected member conditions. Many plans attempt to close as many prospective gaps in a year as they can and whatever they cannot close in that year is sent to retrospective programs. This is an unsophisticated, costly approach that tends to over-suspect and send providers weak evidence which diminishes provider trust and engagement.
Based on CMS guidelines, the prospective format has very specific language requirements for how providers document member conditions. Plans cannot go back in time and change how its providers code and document a condition, thereby making retrospective programs administratively heavy.
AI machine learning models offer a higher level of sophistication by scanning the clinical evidence and assigning a probability score to each piece of evidence in support of a suspected member condition. This saves administrative time and offers providers a high level of trust that the data sent via CDI alerts is compelling and indicative of a condition. When providers have confidence in the data, it increases their participation in prospective programs and leads to more gaps closed.
Tune in to this episode to learn more about AI suspecting program logic and prospective programs.
About Our Guest:
Elizabeth Burreson is an expert in risk adjustment analytics technology and has 20 years of IT data management experience, managing product portfolios and backlogs.

Medicare Ad Graphics—The Overlooked Element Aug 01, 2023

Show notes

Medicare marketing is evolving as more seniors engage with digital news, social media, and video. Yet treating everyone over 60 as one audience can undermine campaign performance. Effective advertising requires understanding generational differences and continuously testing creative elements, from messaging and imagery to video and captions. It's important to remember that insights gleaned from ad performance tests are ever-evolving, so what seems to be true today could change tomorrow. The best strategy includes an AI model where target segments are constantly evolving with updates from multiple input streams such as demographic information, claims data, and digital interaction data, followed by analysis from a behavioral scientist to ensure the message is relevant, timely, and maximizes engagement. Discover how smarter segmentation and testing can improve Medicare advertising.

About Our Guest: Holly Wolniakowski has over 20 years of experience in content development and analysis, PR and media relations. She has unique expertise in the development and management of ad campaigns for government-sponsored health plans. Wolniakowski holds a Masters degree in advertising and a Bachelors in journalism from Michigan State University.

A Business Case For Interoperability May 01, 2023

Show notes

CMS’s Interoperability and Patient Access Final Rule is designed to connect healthcare systems and give members greater control over their data. Required APIs enable members to access health information, help providers locate network resources and streamline prior authorization, and allow health plans to exchange data when members switch coverage. This continuity supports better care, faster gap identification, and improved member experiences. However, implementation can be challenging for plans without in-house technology teams. Specialized partners can help build secure authentication, protect sensitive information, support compliant data exchange, and create systems that turn interoperability into meaningful business and care opportunities.

About our Guest:
Brian Edwardson is the Director of HEDIS Operations. Edwardson has a longstanding career in healthcare technology and quality data. He joined the product team to build and launch a quality, provider engagement, and interoperability products. He is a Certified Product Owner/Product Manager (POPM) delivering products in the Scaled Agile Framework and he holds the third level of certification, PMC-III, from the Pragmatic Institute Product Management. Currently, Edwardson leads a quality performance team that supports multiple health plans.

How Technology Workflows Influence Quality of Care Apr 04, 2023

Show notes

Technology is essential for today's care management operations, yet it's important to recognize that technology can either help or hinder the business. At its best, technology offers a reduction in the basic cost of doing business through streamlined workflows, automation and digital processing of administrative functions. But, at its worst, improperly designed technology can cause wasted man hours, rework, increase the likelihood of human error, and create job dissatisfaction—all of which creates staffing issues and distracts clinicians from the primary mission of caring for members.
About Our Guest: Laura Franklin has over 15 years of clinical nursing experience and 8 years with healthcare technology platforms guiding clinical informatics. Franklin is an Advanced Practice Nurse, MSN from UCSF.

Listen in to learn more about how innovations in workflows for case management and utilization management are solving common healthcare and business problems for health plans.

Ethics, Data Science, and SDoH Mar 01, 2023

Show notes

Social determinants of health (SDoH) is an important variable to consider when interacting with Medicare Advantage populations and as the healthcare system increases its use of digital technologies, such as telehealth visits, online prescriptions and digital communications, digital inequality is becoming a forefront issue within SDoH.
Digital inequality examines populations to determine internet accessibility, internet literacy, and how are people of different sub-populations are using the internet. All of these factors influence how plans should develop messaging and outreach programs.
In order to collect this information and develop solutions to reach this population, health plan data scientists have to be conscientious of SDoH when building algorithms to avoid biases. For example, a new strategy for closing gaps is to offer telehealth services. To test the efficacy of this strategy, a health plan may build a model to predict a member's likelihood of using telehealth services using cohorts of urban versus rural member data. If they don't include data related to digital inequality, they may come to a faulty conclusion that telehealth is a good solution for its rural members. By not accounting for digital inequality, the telehealth program may result in poor engagement. By including SDoH data, health plans can identify micro-segments of the population and innovate solutions to address each cohort. In this case, the health plan might plan to partner with an internet service provider and pay for a portion of the internet fees to enable their offline member's access to telehealth visits.
The takeaway is the data used to feed algorithms must be consistent with the population the logic is applied to. One way to ensure that models are built accurately is to ensure data science teams are well rounded and include not just highly technical data scientists but also social scientists to account for the specific needs and challenges of any given population.
About Our Guest: Brandon Brooks is a Data Scientist for Member Acquisition & Engagement technology, a machine learning solution for Medicare Advantage plans. With over ten years of experience in computational social science research, he is an expert in human communications and engagement in digital ecosystems using data and behavioral sciences. He’s worked in several industries including healthcare, energy, environmental, education and information technology. With an appreciation for details and analytics, Brandon is highly skilled at telling stories with data and enjoys working on complex problems without a clear solution.

Leveraging HEDIS Data Feb 01, 2023

Show notes

“The goal is to support consumers in making informed decisions about which plan to choose”

HEDIS hones in on 5 domains of care and measures whether the healthcare services rendered are actually improving conditions. The domains include effectiveness of care, access or availability of care, experience of care, utilization and resource use, and information about the health plan.

In the domain of access or availability of care, advancing health equity and improving quality of care for underserved populations is an up and coming topic that the NCQA is focusing on. There will be a requirement, tentatively set for 2024, for health plans to have race and ethnicity data on 80% of a health plan’s population. Health plans should be auditing their member information now to identify incomplete information sets and develop a plan for incorporating the right data into race and ethnicity stratifications. This data can be sourced directly or indirectly. Direct data comes directly from the member. For example, from a survey, enrollment information, or even requested from provider’s EMRs. Indirect data is the practice of using data for a purpose other than the reason it was originally collected, such as census data.

Another change we can expect from the NCQA is the shift to acquire more electronic sources for data collection. They’ve started to develop specific measures, Electronic Clinical Data System sets, ECDS. It’s not required today for the Medicare Advantage population, but this should be on every health plan’s radar because it will be a NCQA requirement in the future.

HEDIS data is valuable beyond HEDIS. Forward-thinking plans can leverage the output of HEDIS data to support CAHPS and HOS. The data can be pushed downstream to other areas of the business to provide member-level insights like member compliance for care management teams or member communications. This is where risk adjustment—closing gaps, health management, communications, and member experience intersect. This should be each health plan’s future goal—to have a holistic model where all business units are on the same page, fueled by the same data and working together towards the same goal.

About Our Guest
Alyse Schwartz is the Director of HEDIS Analytics. Alyse holds a Master of Science degree in public health with a focus on epidemiology. She’s an experienced researcher and has been in the quality improvement space for over 10 years.

The Technology Debt Dilemma—Why Cloud Operations Are Essential Jan 02, 2023

Show notes

Technology debt makes legacy health plan systems expensive, slow, and difficult to change, limiting innovation and competitiveness. Cloud technology offers a path forward by improving scalability, flexibility, and speed. Rather than simply moving existing systems online, health plans can adopt cloud-native tools and infrastructure designed for modern software development. This enables faster scaling, greater automation, stronger connectivity, improved security, API management, and better governance. In this episode, explore how moving beyond legacy technology and embracing the cloud can reduce costs, accelerate innovation, and help health plans respond more effectively to constant change.
About Our Guest
Larry Moncol leads healthcare operations product software and technology platforms.

Innovations In Claims & Payment Models Dec 05, 2022

Show notes

It’s hard to imagine a time when claims were submitted on paper. In 2003, Medicare required electronic submission of all claims via an electronic data interchange (EDI) for auto-adjudication. This means claims are processed, paid, and have a status update without human contact. Plans should aim for an auto-adjudication rate in the high 90’s, but some systems still struggle with this benchmark.

There are a number of system errors that can impact auto-adjudication rates including faulty matching logic, incorrect claims information, and missing provider contracts to name a few. Information maintenance is critical to a successful auto-adjudication process, otherwise it front-end rejects or receives a pending status. In these cases, a manual correction is required and not preferable, as human resources are costly. In order to stay competitive, plans have to invest in a strong adjudication engine that can handle high volume.

Another area of investment that behooves plans to prioritize is the configurability of their claims processing technology. A high level of configurability allows for faster response to change such as: CMS regulatory updates, changes to the health plan’s plan types, benefit plans, contracts, provider contracts, capitation-related contracts, payor information, bank information, group information, member configuration, authorizations. There are a number of variables that must be accounted for and having a system that is highly configurable takes the edge off of changing with the times.

About Our Guest
Kirsten Lynch is a product manager and claims technology expert who has been in the healthcare industry for over 20 years.

Generational Differences In Technology Usage Nov 01, 2022

Show notes

The concept of marketing segmentation isn't new, but what may be new, is the idea of generational segments within the Medicare market. Until recently, messaging to the senior market has involved painting a picture of a peaceful and relaxing retirement. The Silent Generation, born between 1925-1945, responded very favorably to this messaging. And many of the older Baby Boomers, born between 1946-1954, also respond well to this promise of peace, although not all.
The younger Baby Boomers have absolutely challenged the norm and the expectation of what it means to age, and they're not resonating with this ideal of retirement. They feel they're just getting started and respond best to the promise of adventure and exploration. A 2018 Columbia University study found "considerable evidence for age-group dissociation" meaning today's older adults don't see themselves as old.
And it's not just messaging that's changed with the younger Boomers. The tactics and channels have changed too. Whereas older Boomers still prefer word-of-mouth, traditional marketing, and in-person opportunities, like agents; younger Boomers prefer a transactional relationship that maximizes value and efficiency.
Another concept not widely considered in the Medicare market but certainly avant-garde, is messaging aimed towards Generation X and the Millennials. As the insurance space becomes increasingly more digital, it may be perceived as confusing or intimidating to aging-in seniors. In many cases, seniors are looking to their children and even their children's children to help them navigate online platforms and even the growing complexities of health insurance. Generation X is not the first generation to help their parents through the aging process, but they are the first generation to understand things that their parents may not. They're essentially taking the place of agents in some cases. This aspect of Medicare marketing is an under explored area of opportunity. There are some data points that can indicate whether you're interacting with a proxy, although this concept is in its infancy. Perhaps the greatest benefit of interacting with future generations as proxies is the opportunity to build rapport and members for life.
About Our Guest
Marcie Robinson-Caughey has been studying senior programming for 20 years. She began her career in operations and marketing for senior community recreation programs. Today, Marcie is the Operations Manager for Digital Outreach platform.
References
Weiss, D. & Kornadt, A. E. (2018, October 19). Age-Stereotype Internalization and Dissociation: Contradictory Processes or Two Sides of the Same Coin? Current Directions in Psychological Science, Vol 27(Issue 6), page(s) 477-483, 2018.

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