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The Voice of Elena Martin
As more and more health systems and provider organizations successfully manage the shift from patient care to population health management, long-term health plan strategic planning should be blending network strategy with product strategy as a key indicator of the ability to achieve clinical and financial goals. The majority of providers are savvy at managing pay for performance and upside risk arrangements, and as providers have seen the margins narrow and plateau, plans have had to adapt and move beyond simple incentivizing for behavior change. We heard from the Centers for Medicare & Medicaid Services (CMS) the Accountable Care Organizations (ACOs) with upside-only risk have not performed as well or increased savings in comparison to those ACOs with downside risk and skin in the game. Systems that have ventured into managing downside risk and percent of premium arrangements and that have been successful have an appetite for more. Certainly moving up the food chain from a provider to a payer has been a topic of conversation among CEO’s of large integrated delivery systems. They have worked hard to align physician trust and referral networks, build a strong name brand in their local communities, and negotiated contracts with health plans that have met and exceeded care and cost containment goals, and the question of where do we go from here is top of mind.
In early February, there was a bit of a scramble when several plans received notices they had approximately a week to submit their Health Service Delivery (HSD) tables for a network adequacy review. Fortunately, for some, the communication should have indicated the gates were open for plans wanting to test adequacy and receive technical feedback. While it was a stressful 24 hours pending the Centers for Medicare & Medicaid Services (CMS) response on the notice, we hope the false alarm sparked the much needed jump-start to ensure a compliant network adequacy monitoring program is in place.
The Centers for Medicare & Medicaid Services (CMS) issued its Round Two online provider directory review, and the results were dismal. Plans reviewed showed an overall inaccuracy average higher than Year One plans. We can try to marginalize the results and say the average inaccuracy found by location was 48%. Nevertheless, the fact remains that nearly half of all directory locations reviewed were inaccurate. Breaking it down further, the inaccuracies ranged from 11% to 97.82%. We are living in an age of tech-savvy consumerism. If our GPS or Google results proved incorrect half of the time, we would not be satisfied. If results proved correct less than 3% of the time, we would be outraged.
As anticipated, the Office of Management and Budget (OMB) approved the Centers for Medicare & Medicaid Services’ (CMS’) move to network adequacy reviews on a three-year cycle, unless there is a triggering event that would reset the timing of a Medicare Advantage Organization’s triennial review.
Many of you and your teams are in the frantic, end-of-year trenches renegotiating current provider agreements or working on contracting new providers for a service area expansion, and it is easy to lose sight of all the changes swirling around the provider network arena. As we head into 2018, we would encourage you to incorporate these three key items into your Provider Network Management Department’s performance appraisal goals.
If the Centers for Medicare & Medicaid Services (CMS) knocked on your door today, would you be ready to submit a compliant provider network within 60 days? CMS estimates the proposed three-year network adequacy review for Medicare Advantage (MA) plans would mean just that for approximately 304 MA plans for calendar year 2019.
The summer sun is shining and vacation season is in full swing! While our Health Plan Network and Product teams are taking a few deep breaths after application and bid filing deadlines, we cannot rest on our laurels for very long. Summer is the best time to start planning your next service area expansion (SAE) or even your first step into the Medicare Advantage (MA) world. Maybe you are an established MA plan evaluating where to expand your geographic footprint. Maybe you are a Medicaid plan looking to expand into the Managed Long Term Services and Supports (MLTSS) arena and are wondering what it would take to have a Dual Eligible Special Needs Plan (D-SNP) so many of the MLTSS Requests for Proposal (RFPs) are expecting; or maybe you are an Accountable Care Organization looking to leverage your infrastructure and enter the payer world. Now is the perfect time to start planning for your 2018 and 2019 network needs. Regardless of the size and scope of the organization, your plan’s network adequacy and accessibility is a cornerstone of any new initiative. And, Plans need to be even more vigilant in managing their largest asset