Earlier this month, the Center for Medicare & Medicaid Services announced that they will be calculating 2020 risk scores by adding 50% of the risk score using diagnoses from encounter data (supplemented with diagnoses from RAPS inpatient data) and FFS data and 50% of the risk score calculated (using the 2017 CMS-HCC model) using RAPS and FFS diagnoses. This doubles the current percentage of encounter-based risk scores used for the final calculation, meaning every encounter reported up stream will soon be more important than ever.
Value-based care offers Medicare Advantage Plans a Path to More Market Share.
Value-based care offers Medicare Advantage (MA) programs an important opportunity to capture market share. Ranging from cost savings from the reduction of medical errors, to providing benefits, such as transportation, it's clear why health plans are innovating on these options. Consumers though, still don’t know which plans are making investments to create better healthcare options for them. Their perception is that, aside from cost, most MA plans don’t differ, which is an opportunity for plans to differentiate themselves from their competitors.
There was once an assumption that the expansion of Medicaid would yield recipients consuming more primary care services rather than seeking out the Emergency Room as their first stop in health care decisions. Several years after the inception of the Affordable Care Act, we’ve learned this is not the case. A recent Washington Times article pointed out that Medicaid expansion has, in fact, not pushed those using Medicaid benefits to PCPs, rather it has increased the traffic to emergency rooms. So, why are Medicaid recipients two times as likely to seek out care at the emergency room rather than a lower-cost option or using their primary care provider? Simply put, it comes down to benefit design, education, and ultimately consumer engagement. In populations like Medicaid, where benefit design and education on health care consumption are not widely understood or properly communicated, there is poor engagement, which perpetuates inappropriate benefit use.
It's no secret that member confusion around how to use medical benefits continues to be a major driver in inappropriate health care spend. For the Medicare population specifically, a recent Healthmine study showed that only 22 percent of Medicare Advantage members have knowledge of what star ratings mean when it comes to choosing their care. This confusion and lack of knowledge often gets highlighted through the statistics shared around inappropriate benefit utilization (such as inappropriate emergency room visits) and the expenses incurred as a result of chronic conditions.
Finding and eliminating gaps in care continues to be one of the most challenging aspects of the shift to value and better outcomes. As perhaps the most influential payer of all, Medicare is emphasizing shared savings programs to incentivize delivering quality care. Additionally, there has been an industry-wide shift where the focus is no longer on disease management, but rather on population health management as a whole. This makes the opportunity to impact care gaps and quality a much higher priority for at-risk organizations.
Thanks to the proliferation of technology, patient expectations are sky-high. After all, providers and plans are competing with some of the best brands in the world when it comes to delivering on consumer expectations. Which might be why patient engagement might actually matter more than ever. In fact, outbound engagement is proving to be an effective way to stay connected with members and control populations. Expanding access to healthcare solutions impacts the bottom line of providers given that better access often translates to prevention.
Our employees pulled up their sleeves, dug in the dirt and shoveled mulch as part of the United Way of Greater Portland’s Dirty Hands & Big Hearts Day of Action. Day of Action is an annual day of service sponsored by the United Way. Volunteers from all over greater Portland come together and spend the day completing 75+ enhancement projects at local non-profits and schools. Citra employees participated in three specific projects this year.
Today’s healthcare professional knows that meaningful patient engagement is the key for managing to successful outcomes. Defining impactful engagement and patient success criteria, which promotes better health and drives patients to better outcomes is our focus.
The number of Medicare beneficiaries continues to rise with our aging population and the growing number of Medicaid recipients are challenged with the impact of social determinants of health. Both populations need timely, accurate and clinically grounded information when faced with healthcare decisions. The trusted, convenient and reliable services of URAC accredited and NCQA certified Nurse Call Centers are proven to increase care access, help ensure proper utilization of services, and produce better care outcomes by decreasing unnecessary emergency department costs.
Paul Carr currently serves Citra as our Senior Director of Customer Support. In this role, Paul has direct accountability for leading the team, whose efforts address our clients' support needs every day. Throughout his career, Paul has led global technical operations and service delivery teams in support of Fortune 500 companies operating within the telecommunications, financial services, manufacturing, retail and healthcare industries. Additionally, he holds a BS in Human Resources Management from the University of Massachusetts and an MBA from Bentley University.
Paul moved from the Greater Boston area two years ago and now lives in Portland. His daughters, Paige (26) and Victoria (24), are both PharmD candidates at the Massachusetts School of Pharmacy. His Son Rex (21) is a third year Finance major at Wake Forest University.
When not shoveling snow, Paul enjoys hiking, biking, SCUBA diving and spending quality time at "The Camp" near Lubec, ME.