Now that you have digested the Centers for Medicare & Medicaid Services’ (CMS) announcement on the proposed demonstration for high-value benefit designs, the clock is ticking on determining an optimal set of benefits prior to the CMS deadline of November 15, 2015.
Over 37 organizations are eligible to consider this opportunity, which is based on member value and not competition. As John Gorman, Founder & Executive Chairman at Gorman Health Group, and I discussed at length on our recent Medicare Advantage Value-Based Insurance Design Model (MA-VBID) webinar on Monday, a multi-faceted approach within the health plan operation will be needed to quickly put together a review and proposal. Operational “must haves” include high-value, narrow networks which understand the eligible populations, high-quality disease management programs, solid Star Ratings programs, and predictable membership. A strong foundation in claims processing and configuration, product design (including supplemental benefits), return on risk adjustment, efficient organization staffing, and excellent communications (electronically) with providers are needed to support the required capabilities.
Although marketing to the target populations will take place post-enrollment to limit adverse selection, the concept of a target condition is based on two key triggers. Realistically, the target condition is marked on a claim with several months’ run-out, even if a need already exists such as follow-up visits to specialists or prescription drugs. Good Electronic Medical Record (EMR) communication can shortcut that process to activate benefits. Fortunately, drugs can be targeted for benefits, but Pharmacy Benefit Manager (PBM) coordination is critical.
GHG has been preparing for this shift in the industry and is already working with clients to assist in the assessment of current providers, referral patterns, and populations within the eight chronic conditions (diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and various International Classification of Diseases (ICD) combinations). Understanding the cost and utilization as well as referral patterns for these members (medical and pharmacy) will help a plan maximize the potential for success. A team of subject matter experts from Gorman Health Group will deliver actionable results, driven by data analysis of current capabilities and benefit designs, to achieve quality care for the target populations.
The benefits must be approved with November submissions and certified by the plan’s actuaries with the 2017 bid in June 2016, so they are binding. Gorman Health Group is prepared to help with individual plan assessments and partner with clinically-effective benefit designs that deliver financial and quality results.
GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you’re keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>
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Download a copy of the recording from Monday’s Medicare Advantage Value-Based Insurance Design Model (MA-VBID) webinar, hosted by John Gorman.
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