Innovation and Quality must go hand-in-hand

Plan sponsors are waiting with anticipation for their 2014 Medicare Star Ratings to be released. Just yesterday, Tufts Health Plan in Watertown, Massachusetts released the news that their Medicare Preferred HMO plan was awarded 4.5 out of a possible five stars. It reminds me of the old Ford commercial jingle where they said “Quality is Job 1”. No truer words apply when it comes to maintaining high quality plan options for our nation’s Medicare beneficiaries.

Recently I accompanied our founder and executive chairman on a field trip, where he enthusiastically addressed a large group of health plan decision-makers as part of their series on innovation. Now, innovation and quality do not always go hand in hand. I have purchased my share of aftermarket tech products to know that while a company might have employed innovation to make something less expensive, often times, it comes at the expense of quality. It’s deflating when you finally get on your train with your discounted charger, plug your phone in, and you see the magical words: “not charging”. Add it to the list of our countless first world problems, but it illustrates the point.

With the bonus payment going away for any plans earning less than a 4-star rating in 2015, 3.5 stars will not cut it, especially if you are counting on those funds or have incorporated them into your future year’s budget. During his presentation, he drew our attention to outcome measures, and how heavily weighted they are. There are so many opportunities for a plan to innovate, not only for purposes of increased quality rating, but also for the most important factor of a plan: its membership. Loyalty can no longer be bought with just the $0 premium plan anymore. The customer service has to be stellar; their enrollment experience must be error-proof; and in times of sickness, when their utilization has to increase, the care management has to be more than just a pre-auth and a smile (and sometimes you don’t get the smile). It is time to have a discussion in every department:

  • What are we doing to be innovative?
  • What are the best in the nation doing?
  • What’s low-hanging fruit and what requires more significant investment?

Our health plan partners are becoming more and more engrained in government programs, including Medicare Advantage, Part D, Medicaid, Duals, and the Marketplace. He also reminded us that organizations should be prepared for constant regulatory oversight, which comes with government-sponsored programs. True, some of the regulations are a challenge to implement, but when you’ve gotten to the point where you have met your compliance requirements, think about ways your organization can supplement that success to exceed a member’s expectations – within the rules of course. Who is the town crier at your plan for the beneficiary’s experience? Why can’t it be you?


Coming soon: GHG’s updated star rating database.  We’ll send an alert when it’s ready! Join our subscription list to be sure you know when this free download is available.  In the meantime, take a peek at last year’s database that combines the CMS-issued 2013 Star Ratings with those over the program’s history from 2008 on.

Register to attend our October 29 presentation “Inside the 2014 Star ratings for MA and Part D: Trends and their implications.”

GHG Pharmacist, Lynne Civin, outlines the benefits of daily dispensing requirements in a new article: Short-Cycle Dispensing for Long-Term Care. Lynne discusses  key attributes in long-term care , and outlines critical items that warrant further discussion. Download the whitepaper today.

The percentage of plan with an average or below average star rating is staggering – and CMS has made it clear, average just isn’t good enough. Learn how GHG can help your plan effect meaningful change in your Star Rating and beat the curve.

Regan Pennypacker
Regan Pennypacker

Regan is Senior Vice President of Compliance Solutions at Gorman Health Group (GHG). She leads the Compliance Solutions practice, responsible for multidisciplinary projects such as Part C and Part D audits, new applications, marketing material reviews, risk assessments, and training engagements. As a member of this team, she has provided compliance direction and insight on industry best practices to many GHG clients. Regan brings GHG clients 19 years of experience in the healthcare industry. Read more

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