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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.

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