News & events in
Precision

Empowered
CARE MANAGEMENT

  • Moment of Need Comes Earlier Than We are Treating It

    by User Not Found | Feb 17, 2016


    My friends who are primary care physicians have all described a common occurrence in their practices and they do so in nearly identical terms. Perhaps this scenario sounds familiar. The patient in the exam room is a 50-­year-­old woman, presenting with a coterie of symptoms and complaints around pain, sleep and frequent ailments. With very little prodding, she breaks into tears and says she is angry, frustrated, lonely, trapped, disappointed and scared. “I have reached a glass ceiling at work,” “there’s no intimacy in my marriage,” “I feel so lost and lonely,” or, “I just hurt … ”

    But it is minute 10 of the 13 minutes the PCP spends with each patient and he or she can’t destroy the schedule and generate long patient wait times. Physicians tell me they have great empathy for this patient but don’t have the time nor the training in behavioral health screening required to diagnose or treat her. And even if they had the time, they lack the coding expertise to ensure they are fairly compensated for their efforts. They also know that suggesting a psychiatric visit will be met with resistance due to stigma and a lack of trust. Time, money and stigma are hard barriers to overcome.

    So they reach for their pad and scratch out a prescription for an antidepressant or antianxiety medication, offering words of reassurance: “What you are going through is normal ... this medication will help ... make an appointment to see me again …” The PCPs make the best decisions they can for their patients’ health and well-­being, despite very real constraints and limitations.

    Think this is a very rare occurrence?

    Reaction Instead of Genuine Response

    Research shows that in 2007 nearly 12 percent of primary care visits resulted in prescription of an antidepressant medication – nearly double what it was in 1996. What is startling is how many of these prescriptions are written without an actual psychiatric diagnosis. That rate has increased from 59.5 percent to 72.7 percent. An analysis found that those at highest odds of receiving such a prescription without diagnosis were:

    • Women more than men
    • Aged 50 and older more than any other age
    • Patients with two or more medical diagnoses
    • Patients with diagnoses of heart disease or diabetes

    This profile is similar in many ways to the population we regularly serve in Health Integrated’s Multichronic Care Management (MCCM) program. MCCM members have multiple chronic conditions, high psychosocial risk factors, at least one diagnosed psychological condition, and are frequently prescribed antidepressant and/or antianxiety medications. By the time they enroll in our program, they have spent years reacting to symptoms, complications and comorbidities, without ever directly confronting the root cause/s of their health vulnerabilities – their behavioral and social risk drivers.

    These patient stories and the research persuade me that they are both describing our MCCM member years before she ever enrolls in our program. When she saw her PCP, she received medication that lessened her pain or treated her other symptoms, but did nothing to address her real health drivers. Instead of identifying and addressing her fears, anxieties and barriers through validated talk therapy interventions, she more than likely pushed them deeper inside and for years followed that all-­too-­typical path of slow self-­destruction into moderate to severe obesity, substance use and the burden of multiple chronic conditions. Years later, she has accumulated more risk, added one or more psychiatric diagnoses and has undermanaged her chronic medical conditions. She is now the right candidate for MCCM, which provides members like her with therapeutic care management.

    Acting Sooner Could Save Suffering and Cost

    But could we have done something better for her when she first presented at her PCP’s office? Could we not have integrated low­-stigma, highly competent and fairly compensated psychosocial assessments into the primary care setting? Could we not have then given the PCP a tool kit of validated intervention pathways to build into her care plan? An estimated 60 to 80 percent of all primary care encounters are driven by a patient’s behavioral need. Patients and health plan members are clearly telling us what they need and want from their PCPs. Skill sets and compensation models must evolve and we at Health Integrated think our therapeutic model for Precision Empowered Care Management™ can play a critical role when integrated into the practice setting. In doing so, we can drive sustainable risk reductions and avoid the costly and devastating complications from unmanaged medical, behavioral and social vulnerabilities.

    Tracy W. Korman is executive vice president of Innovation for Health Integrated.

  • Rock the MOC! It's Evaluation Time ... (Part III)

    by Jane Scott | Feb 08, 2016


    In the last two segments of this series, I talked about evaluating your plan’s Model of Care (MOC), including data, measures and the mistakes some SNPs make during evaluations. Now let’s get down to business and cover some practical considerations for quality improvement processes and recommendations for your next plan year. If this is your first written evaluation, what format will you use and what will your stakeholders expect? Will you follow the plan format used for your annual quality improvement evaluation? Do you have stakeholders who need the data in a certain format so they can better digest it? If you did not indicate in your MOC how you would present your evaluation, it’s time to hold an internal discussion about the best way to explain your data and outcomes.

    Did you make your list of data points from MOC 4? If not, please do so. After you look through your HRA performance data and care plan completion rates, step back and ask yourself, “What other operational areas within our plan that are not reflected here might put us at risk?”

    The purpose of your annual MOC evaluation is to identify the clinical, operational and outcomes aspects of your model that need improvement. Plans must put corrective action processes or interventions improving the model into place and articulate a process for measuring changes. This is where many plans fall short. Instead of showing a truly effectuated “Plan, Do, Study, Act” cycle with measured improvements, some plans simply change their goals. Now, what does that say?!

    Denied Claims and Out-of-Network

    Most plans list goals like “improving access to care” and/or “appropriate use of benefits in the target population.” If your plan’s care management system is not configured to map interventions to a benefit class or category, how is your plan identifying and measuring access? Are you looking retrospectively at claims data/utilization? Mining claims data for genuine outcomes can be much more valuable than any general or supposed outcomes you would get from collecting HEDIS data or gathering data through exclusion methodology.

    To start, take claims data from your SNP population for the prior year and filter it by PCP visits and visits to the predominant specialty providers. Sort claims for each of these categories against ICD-9 and ICD-10 codes and revisit the disease statistics you laid out in MOC 1. Do they align? Do you need to re-evaluate the disease states of your target population in light of your findings? Don’t overlook a service encounter just because a claim was denied or the service was delivered out-of-network. In fact, it makes sense to analyze out-of-area claims for access issues. Does the specialty provider encounter-data align with the disease states of individual members? Does the data reveal that your care plans or assessments are missing anything? Has your plan aligned ICD-10 logic with your population’s disease prevalence as it was first outlined in your MOC? Are you are capturing your data event and mapping the data correctly?

    For the sake of goal measurement, let’s discuss community services access. As we all know, many SNPs cannot successfully manage their populations without community providers. Since these providers are typically not contracted with plans, out-of-network utilization patterns cannot be tracked until claims come in. Thus, plans must rely on the integration of these providers into care plans. Ask yourself whether you are effectively measuring the use of community providers. Do you need to configure your system to document their use? Get specific! Don’t just make the generic statement: “We refer 20 percent of our patients to the community food bank.” Instead, identify the disease states of patients who are accessing community services and document why they are using them. What does this tell you about how well your care managers are managing plans (or not) and, thus, whether they are fulfilling the purpose of your SNP?

    Dig for Root Causes

    While many D-SNPs have the enrollment verification process down, I-SNPs and C-SNPs have to rely on documentation from folks outside the plan to qualify enrollments. How does your I-SNP or C-SNP fare in this process? Does the outside institution verify levels of care and pass that information along to you in a timely manner? Are lengths-of-stay meeting requirements? Is a quality improvement program needed for this process? Have your internal monitoring and auditing teams identified any issues? How is the corrective action coming along?

    I have posed many questions in this blog posting because addressing them is an important exercise for plans as they work through their annual evaluations from start to finish. Ask tough questions and keep digging for root causes so you can redesign. Get the audit protocol document, review the universe format for the evaluation and performance sections, validate that your plan can indeed populate it, then identify start dates, end dates, and baselines or benchmarks. Many plans wrote their MOCs several years ago and have not reviewed their MOC 4 section structures. These need to align with audit expectations for the universe data.

    A few simple and smart steps can ease the pain of writing your evaluation and actually make it a fun, worthwhile exercise! Who would ever think that writing an annual evaluation could be fun?  ;-)

    Jane Scott is senior vice president of Professional Services for Health Integrated.

     

     

  • The Lingering Power of Stigma

    by Sam Toney | Jan 22, 2016


    Educating the public about mental illness in an effort to reduce stigma has proven a double-edged sword. Research shows that as people have increasingly accepted that mental illnesses are biologically based, they continue in their discomfort with or outright fear of people with these diseases. On the one hand, understanding the role of biology has gained more empathy for people with depression, but has actually worsened the image of people who have schizophrenia. Many people still feel that schizophrenics may become violent and are hopeless to treat.

    This is not something that an anti-stigma brochure is going to help. The former president of the American Psychiatric Association, Steven Sharfstein, said in 2012 that negative attitudes toward persons with serious mental illnesses are unlikely to decline “as long as there are untreated, delusional, disheveled, threatening homeless individuals on our streets and in high-profile media examples of violence.”

    Nearly half of Americans blame a faulty mental health system for the violence we hear about in the media. Yet, as mental health advocates keep reminding us, the seriously mentally ill are more likely to be victims of violence than to be violent themselves. Although it is a complex problem, research shows exposure to abuse and violence early in life are much greater risk factors for violent behavior in adulthood. As researcher Dr. Jeffrey Swanson* notes, this kind of trauma is not something you solve by having someone take a mood stabilizer.

    Public Education Has Limits

    Reducing stigma is clearly more difficult than advocates perhaps anticipated. While Americans have come to recognize the disease model, the majority still say they wouldn’t want to work with a mentally ill person or have one marry into their families. Some mental health advocates have called into question whether the resources that were spent on traditional public education programs were worth it, considering the results.

    So what does work when it comes to reducing stigma? Research shows that meeting someone with a mental illness face-to-face is two to three times as effective in reducing stigma as an informational program. Engineering a solution along these lines, however, seems impractical and again raises the question of whether resources would be better spent on treatment or research.

    Ironically, most of us are already related to, working with, or socializing with the one in four Americans who have diagnosable mental illnesses. These folks don’t fit a stereotype and that is why we don’t recognize them. Of the one in four, many do not understand their own symptoms and might react badly to the suggestion that they need help. This is the major reason 57 percent of Americans with diagnosable behavioral health disorders are not receiving treatment. And therein lies the problem. Stigma isn’t just an impolite response. Overcoming it isn’t a matter of political correctness. Stigma discourages people from seeking help and from following a course of treatment.

    To get around this, innovative models are being used that realign first encounters with the mental health system. Telephonic interventions in the privacy of a person’s home seem to make discussing personal issues less threatening. These start with conversations about immediate health concerns and goals, which may uncover indicators of underlying mental illness. Introducing mental health concepts as part of a whole-person health conversation reduces stigma and supports an eventual in-person diagnosis and treatment follow-through.

    Other telemedicine solutions hold promise, but technology itself is not the answer. The skill and empathy of a trained clinician make all the difference. Compassion will always be the essential ingredient in bringing mental illness out of the shadows and into the sunlight.

    Dr. Toney is chief medical officer and executive vice president of clinical integrity for Health Integrated.

    *Swanson is a medical sociologist and professor in psychiatry and behavioral sciences at the Duke University School of Medicine.

     

  • Rock the MOC! It’s Evaluation Time … (Part II)

    by Jane Scott | Jan 15, 2016


    In Part I of this three-part series, I discussed the evaluation of a health plan Model of Care (MOC) and a few data points plans might want to consider. Carrying this idea forward, I would like to discuss how CMS evaluates SNP plans when it comes to plan performance and how that fits into your plan’s annual MOC evaluation.

    CMS has set up a great structure through the audit protocol for plans that have not completed an evaluation to their model of care. The first question CMS asks about performance monitoring is, “Did the sponsor (plan) collect, analyze and evaluate the MOC (e.g., specific data sources, specific performance and outcome measures, etc.)? This should prompt plans to ask themselves: Did we really think about this step when we drafted the MOC? Or were we just writing it to meet the application submission deadline? Many plans seek outside consulting help to draft or complete their MOCs; I know because I have been on both sides of this equation. Sometimes the exercise of vetting the data a plan can collect and report on gets missed.

    I have audited many plans that have written MOC goals or data metrics for measuring performance improvement  ̶  the good old “MOC 4.” At audit time, they discover they have not done what they committed to on paper and, worse, cannot do it. What to do? There are several helpful steps for plans that are the newest to the market, as well as those that have never completed an evaluation.

    Get a List Going

    Step one is to review what your MOC 4 says your plan will measure, collect and analyze. Remember that managing your plan’s data and the collection process is a critical part of performance improvement. The essential components of this are collecting, tracking, analyzing, interpreting and acting on what the data presents. Quite simply, those are the criteria CMS will use to measure your plan. The whole point of MOC 4 is to help your plan identify and implement improvements to the current model for care delivery, and to monitor your progress as you make improvements.

    Next? Make a list of the goals and the associated data sources you said you would collect. Place that list into a work plan, just as you would for your quality improvement work plan. That should help you identify whether or not you have a baseline for your data. 

    What if you have no baseline data or your external consultant wrote data points you cannot collect? Don’t panic! Start with creating a list of data gaps. This will include all of the measures your plan said it would collect, the data parameters and what if any baseline was mentioned. 

    There are some common ways that plans fall short in their data collection. Many plans say they will complete all initial health risk assessments within 90 days of the member enrollment date and will do so for 95 percent of their SNP population. This is a great metric, but what if you find that your care management system (which is only a year old) does not report completion rates this way for either individuals or a total population?

    Another example: Suppose your plan promised that the MOC would demonstrate how SNP beneficiaries met all preventive screening measures in accordance with member needs and their care plans. After review, you discover that your care management system cannot report individual intervention types or any care plan goals that were met. Suppose only some of the HEDIS data measures for preventive screening fit the profile or attributes of your population and its needs? Imagine that your care management systems cannot identify every HEDIS gap that would show closure. If this is the case for your plan and the system you use for care plan development, it is time to sit down at the reconfiguration table to discuss changes.

    Rely on Proxy Measures

    Your critical step now is to immediately document the status of your data metrics, what your written measurement was and should be, what barriers to data collection exist (e.g. system capability), and what impact these have on your MOC evaluation. Then determine whether there are any proxy measures that could still be used to collect the data. If so, get going! If your system does not run real-time staff performance reports on HRA completion rates, is there a chance you could run a universe (as described in the SNP Audit Protocol by CMS)? That data could be used in place of a system report.

    Next action: Present the gaps in data/metric findings to your executive sponsor for the MOC. This could be your vice president of quality improvement, medical director or even your chief executive officer. If your plan does not have a designated owner for your MOC, this role defaults to your plan CEO. Should that be the case, is this person aware that this is their responsibility?

    Once the review has been done by the responsible executive sponsor, make a decision about doing one of the following:

    • Using the proxy data as your data source and ensuring that this data mapping/collection continues into the next plan year.
    • Redlining the MOC to adjust for the appropriate data reporting source. This identifies a new baseline while providing chronological documentation for your decision and rationale. Make sure your committee meeting minutes present the same information to your stakeholders.
    • Discussing new measures for the overall MOC performance and documenting the discussions, rationale and final decisions.

    Focusing on evidence-based measures that your plan is able to collect also helps your plan focus on adherence to evidence-based guidelines and drives better provider practices. It also helps guide your benchmarks and insight into where you stand relative to other national and state goals.

    Many plans are tempted by too much enthusiasm when listing measures for MOC 4. This leads to metrics that cannot be mapped or reported by the current care management system. The result is further frustration and failure. Prioritizing work with meaningful data leads to improved outcomes. And that, after all, is the entire point of caring for the SNP population.

    Check back in the first week of February for the final installment of Rock the MOC!

    Jane Scott is senior vice president of Professional Services at Health Integrated.

     

  • The End of Employer-sponsored Health Insurance?

    by Shan Padda | Jan 07, 2016


    Experts of all stripes have been predicting the end of employer-sponsored health insurance for some time. As an employee benefit, it peaked in the 1980s after decades of growth. It has been declining gradually ever since.

    The American health insurance system is the only one in the world designed around employment. It is curious how we came to this situation. As Princeton economist Uwe Reinhardt said, “if we had to do it over again, no policy analyst would recommend this model.”

    Employer-sponsored health insurance began during World War II and is essentially a product of the tax code. Fears of inflation led the government to institute wage controls, and employers looked for ways to compensate employees without having to tax additional rewards. Employer-sponsored health insurance became one of these rewards. A subsequent presidential administration tried to rescind what was supposed to be a temporary tax exemption, but by then such programs had already become entrenched. Further tax breaks followed and employer-sponsored health insurance gained a strong foothold in the 1950s and 1960s. Seventy percent of Americans were covered by employer plans in the 1960s, with virtually everyone else covered by Medicaid or Medicare.

    Excise Tax and Exchanges

    There are many influences that will drive employer-sponsored health insurance out of its present position, but among them is the so-called “Cadillac tax” that will go into effect in 2018 as part of implementation of the Affordable Care Act. This could be a turning point, as it will dramatically affect the insurance plans employers will be able to offer employees. A 40 percent excise tax for employers will kick in on the total value of combined premiums, HSA and FSA contributions after they exceed $10,200 a year for single coverage and $27,500 for families. If current plan designs were to remain just as they are now, approximately 60 percent of those plans (mostly offered by larger companies) would be affected. Employer-sponsored coverage would not be able to compete favorably with the cost and variety of plans employees would have access to on private Exchanges. Employers would have an incentive to shed the administrative burden of offering health plans. Employees in private Exchanges would gain insurance that’s more portable and affordable than the COBRA option that currently becomes available when a qualifying life event or job ending takes place.

    A Role for Third-Party Organizations

    Health insurers are responding to the probable death of employer-sponsored health insurance by taking a hard look at joining the private Exchange market, if nothing else, as a defensive strategy for preserving and growing an enrollment base. Third-party organizations like Aon and Towers Watson are offering private Exchanges that could attract members. “Obviously, our goal is to keep group, group,” said insurance executive Bill Brown in the media recently. But, he acknowledges, enrollment in commercial plans is not expected to grow for a variety of reasons. When it comes to this landmark movement away from employer-sponsored health insurance, many insurance plans and employers are taking a wait-and-see attitude.

    Of the 149 million Americans now receiving health insurance through their employers, most have never known any other system. The cultural shift that would come with such a change would be significant. We should expect cries from many quarters for the repeal of the “Cadillac tax,” and for American attitudes about their health insurance to become a major issue for whomever becomes the next president. There are sure to be interesting times ahead.

    Shan Padda is chief executive officer for Health Integrated.

  • Life After ICD-10

    by User Not Found | Dec 15, 2015

    ICD-10 has brought a new level of precision to the health care data ecosystem and it is starting to have an impact at Health Integrated. It has been a long road to ICD-10. It was first introduced by the World Health Organization in 1993. It has endured many attempts to bring it into the mainstream, replacing the longstanding ICD-9 world that has been sustained since 1979. The benefits of ICD-10 are many, but the top benefit for the data-driven health care enterprise is “precision.”

    A major objective of  ICD-10 is that it will help stimulate programs like patient-centered medical homes, value-based purchasing and accountable care organizations by giving the government and care management organizations better data to work with. Coding in ICD-10 requires an elevated clinical understanding of disease processes, the clinical factors behind a diagnosis and an ability to read and understand lab values and diagnostic reports. Since its inception in October, claims data that support health care payer information systems are starting to be populated with the much more detailed ICD-10 codes. 

    When ICD-9 was first developed, procedure terms like “laparoscopic” and “endoscopic” were unheard of. As an example, consider Disease Management codes for asthma: ICD-9 forced medical practitioners to choose intrinsic or extrinsic asthma, a choice that didn't match the realistic pathology of the disease. With the advent of ICD-10, the identification algorithms used to find patients have become more refined and we have a higher success rate in engaging these patients and helping them get the medical assistance they need to deal with their disease. As our precision in identification increases and more patients engage in programs meaningful to their conditions, there will be a natural decrease in health care costs from more precise and diligent treatment. 

    In addition to the precision ICD-10 now brings, there are a few other inherent benefits:

    1. ICD-10 improves the ability of public health officials to track diseases and threats, dangerous settings and even acts of bioterrorism that might otherwise go unrecognized.
    2. Fewer rejected and fraudulent claims – the potential for ICD-10 is that with more specificity, it will be a lot tougher for hospital coders to lump patients into more severe disease or procedure categories.
    3. ICD-10 aligns better with EHRs, and the transition to ICD-10 will assure that electronic medical records, value-based purchasing metrics, and meaningful-use incentive programs speak the same language.

    9 Additional Benefits, as published by Tom Sullivan of “Healthcare IT News

    1. Measuring the quality, safety and efficacy of care
    2. Designing payment systems and processing claims for reimbursement
    3. Conducting research, epidemiological studies and clinical trials
    4. Setting health policy
    5. Operational and strategic planning and designing health care delivery systems
    6. Monitoring resource utilization
    7. Improving clinical, financial and administrative performance
    8. Preventing and detecting health care fraud and abuse
    9. Tracking public concerns and assessing risks of adverse public health events

    Cisco Perin is senior vice president, Technology and Information Strategy for Health Integrated.

     

     

  • Rock the MOC! It's Evaluation Time ...

    by Jane Scott | Dec 07, 2015

    Now that the plan year 2015 is almost over, it is time for Special Needs Plans (SNPs) to start thinking about writing Model of Care (MOC) evaluations.

    This would be a tough term paper if we were still in college, but it will be tougher yet for plans finishing their first year in the Medicare Advantage market. It can be quite a chore just to gather the data, let alone pore over it to establish a baseline or to determine whether performance improved over the previous year.

    Let’s level set first. The goals of your plan’s MOC evaluation are to review SNP performance, the construction of the care model, and whether the plan is meeting the needs of your target population. Many plans miss quarterly opportunities to gather and refresh their target population data, so mark this as your first to-do. SNP administrators should always be looking for a data refresh so they can show in an evaluation that the intent of the MOC and the population in the service area are on target. It is a good idea to review your enrollment and disenrollment numbers monthly against projections by your sales and marketing department. Many plans overlook this, even though sales and marketing are the first touchpoints for SNP beneficiaries.

    Look Behind the Numbers

    Is your plan on target or has it fallen below expected numbers? If your numbers are low, ask yourself why. When a SNP commits to CMS that they will target a population and then fall short, it is the plan’s obligation to understand the reasons. Is your network adequate? Are you designing benefits in ways that meet population needs?

    For D-SNPs, beneficiaries are eligible because of financial status, but often have just as great a clinical need or as serious a disease state as those in C-SNPs. Thus, an annual MOC evaluation should include a look at marketing and sales efforts, the reasons for disenrollment and how financial and clinical needs are being met for the target population. Go beyond your usual review of HEDIS data and network structure, and examine populations by their basis for eligibility and how they use plan benefits. Or not.  

    Each SNP should have a quality improvement (QI) plan program description and work plan that describes specific data sources and evaluation processes. In my experience, SNPs often become stepchildren to a larger book of business and the QI process gets lost in a larger portfolio of plan types. Some plans offering Medicaid whose only Medicare program is a SNP fail to focus on SNP QI requirements as described in the scoring guidelines. These plans miss having a SNP QI program because if it exists at all, it has disappeared into the Medicaid QI program.

    So what, you may ask, should we be doing as a plan? You should consider collecting and analyzing certain data to determine where your MOC most needs improvement. As well as evaluating your enrollment/disenrollment projections, you should also include reason codes to tease out why members are leaving. If your plan does not have a process to identify and collect this data, consider adding it to your enrollment system. Create a process for follow-up calls to disenrolling members so you can begin a root-cause analysis of any deficiencies.

    Know Your Beneficiaries

    Your target population has varying needs you can better understand by continually analyzing your population statistics and identifying who beneficiaries are, why they are eligible, say because of a disability, and how to address that with your care model. For those eligible primarily for financial reasons, you will want to measure the social services dimensions of your care management program. If your care management system has the capability to report services like delivered meals, and financial programs accessed by zip code and/or disease states, you can evaluate how other benefits are being used or not.

    Much of SNP program design is intended to support beneficiary socioeconomic and behavioral health needs that are not otherwise met by the standard Medicare Advantage Prescription Drug plan. Focusing on these two population characteristics adds great value to a MOC evaluation and provides input to stakeholders and providers that result in better outcomes. For example, consider a measure for your SNP MOC QI work plan that considers community and cultural issues. If a segment of your population has a care manager but does not speak primarily English, find out which services they are actually accessing. Are they matched with providers who can either speak their primary language or who offer translation? If not, this could be a major barrier to care that you as a plan can identify and resolve. Are you sorting out and evaluating members under 65 who have a mental health diagnosis to see if they are receiving the care they need outside the care plan? Some members do not seek mental health care because of stigma, but should be encouraged to access these services.

    Many plans have as a MOC 4 goal or outcome the measurement of benefit utilization, but measurement alone will not improve a MOC design to its fullest potential. A plan should review utilization to reveal which services are not being accessed that should be, considering multiple attributes within the target population. Once these gaps are identified, a root-cause analysis must be conducted (an often-overlooked process), to define appropriate and measurable QI processes. It also helps develop better benefits for the following plan year if you define outlier utilization by population attributes.

    Thinking outside the box about ways to evaluate your target population against thoughtful data points or measures can not only improve overall health outcomes, but offer increased access to care, cost savings and improved satisfaction.

    Jane Scott is senior vice president of Professional Services at Health Integrated.

  • October is here and that means ICD-10 is too

    by User Not Found | Dec 02, 2015

    The deadline to start using ICD-10 codes is here and that means all services provided by HIPAA-covered entities need to be coded properly or not be paid. Health Integrated has worked to see that it is a seamless transition for its health plan clients and will be carefully monitoring data flows.

    The Oct. 1, 2015 deadline to activate ICD-10 CM/PCS coding PCS (International Classification of Diseases, 10th Edition, Clinical Modification/ Procedure Coding System) is here! Unlike prior mandates in other years, there have been only minimal legislative challenges to this deadline and there are not any further delays expected for this mandate.

    So if you’ve been in a foot race to be able to code for events like “Struck by a Turtle” (W5922XA) or Struck by a Sea Lion (W5612XA), now you have the tools to do that ;-) All in all, the industry is likening this to Y2K. There has been a lot of speculation as to the impact and Health Integrated is ready. The key to our approach has been based on the realization that we need to be prepared for both ICD-9 and ICD-10.

    Health Integrated began its initial preparation well over a year ago and we stand poised to receive and manage this new data type. We are anticipating a slow ramp-up adoption across health care and are prepared to handle both data types. Our approach has been multifaceted and includes:

    • Readiness to accept and process client files bearing the new ICD-10 codes
    • Updating our logic and algorithms for patient program identification and stratification
    • Validation of reporting requirements to reflect changes for client application of new codes
    • Specific program application readiness for ICD-10
    • Internal and external education and communication about ICD-10

    It is important to remember the use of ICD-10 codes is not optional and the U.S. government mandates that claims with ICD-9 codes for services provided by HIPAA-covered entities on or after the compliance deadline cannot be paid. Health Integrated’s employees have been working extremely hard over the past six to eight weeks, juggling multiple competing work priorities, to ensure our ICD-10 readiness remains seamless for our clients, with no interruption in our professional services to them.

    Health Integrated will be carefully monitoring data flows beginning Oct. 1 and throughout the month and transition.

    Cisco Perin is senior vice president, Technology and Information Strategy for Health Integrated.

  • Are You Ready for Your 2016 Star Ratings?

    by Jane Scott | Dec 02, 2015

    With the release of the 2016 Plan Star Ratings right around the corner, you’ll want to be prepared with a strong strategy for the changes from the Centers for Medicare and Medicaid (CMS) that will impact your plan. To help you get ready, we have provided tips below about the CMS changes, as well as a white paper summarizing the measure changes: CMS Star Ratings: Sink or Swim and the Water is Rising!

    2016 Stars Update

    • • Removal of Pre-set 4-star Thresholds – If you have been using the pre-determined thresholds as a guide in measuring current and past performance, you may wonder how your performance aligns with others with these thresholds gone. We strongly recommend you mirror the previous CMS methodology in what you create for your plan thresholds.
    • HEDIS Low-enrollment Contracts – Are you one of the plans with membership hovering around 500 or more enrollees? If so, you may not yet have a strategy in place for managing operations within the Star rating system. You may be eligible for inclusion in the 2016 ratings and 2017 bonuses. Are you ready?
    • Returning and New Measures – The 2016 Call Letter and the 2016 Technical Specs issued by CMS clearly identify the measure changes. The white paper Jane has prepared (linked above) details these and offers practical advice on how to address the changes.
    • Temporarily Removed Measures and Retired Measures – CMS may reinstate measures that have been moved to the display page. It is wise to have a strategy for those measures because CMS may bring them back into the fold of active measures.
    • Changes to CAHPS Methodology – The Consumer Assessment of Healthcare Providers and Systems (CAHPS) methodology is one of the most difficult data sources to manage. Despite this challenge, the CAHPS deserves all the attention it will take to assure CMS changes are reflected in your plan's internal understanding and management.
    • Resources for Tracking Performance - Many plans assess their current level of performance by directly accessing data sources such as the Health Plan Management System, the CMS Call Center Data and the Patient Safety Analysis website.

    We will continue to keep you updated on changes with the Star ratings program and how they may impact your plan in 2016 and beyond.

    Jane Scott is senior vice president of Professional Services at Health Integrated.