Have you ever wondered how you can better engage your members? How do you get them to participate in preventive health measures? The easiest way to get answers to these questions is simply by asking the members themselves. In a recent Inovalon study, we went straight to the source for insight on member engagement. We learned a significant amount about motivating members to participate in preventive health programs.
Now that the data submissions for 2014 have come to an end and health plan issuers await responses from HHS on discrepancy reporting and final payments, it’s important to look back at the events of the last couple of months.
EDGE server submission began in December 2014, which was 11 months later than the expected start date. Software development had been in progress since 2013; yet there were limited and intermittent instructions, no proper data, and no EDGE server available for testing.
Ask providers what keeps them up at night, and many will say it’s a patient needing care and not getting it. But ensuring that every patient who needs care receives it— regardless of how busy the provider is and how difficult the patient is to reach—is no easy feat.
Consider the steps involved with providing precisely the right care for the right patient, in the right place, at exactly the right time. We can assume that providers manage their practices differently. Even if you had full-time staff focused exclusively on this task, a few patients would inevitably fall through the cracks.
Since 2012, CMS has been transitioning health plans from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS). In its Final Call Letter of April 6, CMS announced that for the first time, it will use data from both RAPS and EDS submission in the calculation of risk scores for Medicare Advantage plans. Beginning with 2015 dates of service, CMS will weigh data from RAPS submissions and FFS at 90% and data from EDS submissions and FFS at 10%.
The more we study the risks associated with dual eligible members, the more interesting things get. For example, our recent study finds that a dual eligible member is at higher risk for hospital readmission compared to a non-dual eligible member with the same characteristics—and this added risk is not accounted for in the current Star Ratings.
Our study results, published in “An Investigation of Medicare Advantage Dual Eligible Member-Level Performance on CMS Five-Star Quality Measures,” demonstrate that dual eligible members have significantly worse outcomes on a majority of Medicare Advantage (“MA”) Star Rating measures evaluated. Researchers found that socio-demographic characteristics—such as living in a high poverty area—and community resource factors—such as a shortage of mental health professionals—were a main contributor to the disparity between dual eligible and non-dual eligible members, explaining 30% or more of the observed differences in outcomes.