Medicare Advantage Program Optimization

To help increase financial efficiency of healthcare expenditures while increasing quality of care, it is paramount to match your program with an appropriate healthcare provider network and incentivize that network appropriately to maximize the quality and value of care. Baker Tilly can help your organization build and optimize an effective provider network strategy, including:

• Network creation and refinement: Forming a network that covers all CMS-covered service categories, including “CMS adequacy,” as well as special relationships with subset of providers beyond adequacy.
• Identification, evaluation and prioritization of provider candidates: Beyond building base provider networks, supporting the identification and evaluation of which providers to target for value-based care (VBC) programs; prioritizing provider candidates based on a variety of considerations (e.g., provider risk readiness, network and market impacts of selection, stakeholder feedback and requests, and program level requirements); and identifying opportunities to more closely align MA reimbursement with CMS premium cost drivers.
• Risk readiness assessments and improvement strategies: Administering provider risk readiness assessments and formulating collaborative improvement strategies with both health plans and healthcare providers.

The transparency of premium pricing and the direct influence by providers on premiums within MA offer a unique opportunity in the market to pursue risk-based contracts with providers. Whether your organization pursues capitated arrangements, shared savings programs, or hybrid fee-for-service (FFS) with targeted VBC incentive arrangements, a key to contracting success is to consider both the financial performance and operational performance incentive structures required to maximize contract outcomes. The inclusion of operational incentives allows an MA plan to support alignment of provider behaviors with performance metrics required to maintain attractive products in the MA space (e.g., STAR ratings).

Baker Tilly has vast industry experience integrating VBC payment models alongside FFS reimbursements, and defining pathways for providers to increasingly share the amount of financial risk over time, with the potential to enter capitated contract agreements. We also understand the organizational and technical requirements to successfully initiate contract terms across the risk-sharing spectrum, and can help your organization with:

• Designing and operationalizing VBC arrangements: Identifying and utilizing the cost levers within MA contracts, and establishing VBC solutions to address the complexities of VBC arrangements within the MA line of business.
• STAR Rating System improvements: Helping MA plans with proactive reporting against quality measures at the provider and member level, defining program measures and approaches, implementing quality measurement calculations, and supporting quality standard audits to ensure high STAR and quality ratings via incentives around quality of care and gaps in care closure reporting.
• Annual Health Assessments (AHA): Implementing a reporting infrastructure to identify AHA gaps and distribute member gap lists to providers to ensure preventative visits are scheduled and completed.

While the decision to enter capitation arrangements should be determined by provider risk readiness evaluations, the opportunity to engage providers in capitation agreements is higher in an MA setting where there is more transparency into premium costs and more direct influence on premium drivers as compared to other population segments.

While formulating the design of a capitation program, multiple clinical and operational decisions must be made, including defining services covered under the capitation payment, development of incentive models beyond the base capitation payments, and finalizing administrative and clinical delegation decisions. The program definition that results from these decisions will also have definitive implications on core MA operations, including STAR HEDIS, STAR customer service, encounter/diagnosis data capture, network contracting (or sub-contracting) for provider systems with limited specialties, claims processing, and provider directory considerations, among others.

Baker Tilly can assist health plans with the operational implications downstream from capitation arrangements, including:

• Operational capability needs identification and deployment: Defining the implications to your organization as highlighted above, and designing and deploying capabilities as required based on program design choices.
• Encounter data management: Defining and building functional and technical processes to capture member encounters with providers in capitated arrangements and integrating them with the risk adjustment process.
• Member management strategy: Establishing delegation and management approaches between the plan and capitated providers to drive member outreach and satisfaction, ensuring proactive management of customer issues and protecting premiums and enrollment.

While capitated agreements are an attractive contracting methodology for MA, not all organizations are prepared to enter capitated arrangements. If provider readiness assessments determine that more traditional FFS agreements with VBC incentives are more appropriate, or the plan is not yet ready to tackle capitation, there are other value-based options to consider in order to support MA success.

To enhance the effectiveness of MA programs, health plans must optimize their contractual relationships with providers and enable payment models that incentivize provider behaviors to increase quality of care while decreasing costs. Baker Tilly can assist with planning, setting up and executing other VBC contracting arrangements, including:

• Model design: Designing, building, and measuring models used in MA shared savings programs by establishing performance and quality-based incentives and agreements based on financial performance.
• Implementation of shared savings incentives: MA plans are uniquely positioned to allow for shared savings incentives calculated by comparing costs to a percent of premiums. Baker Tilly can help with establishing and implementing performance and quality-based incentives and agreements based on financial performance, while also lowering costs and increasing the quality of care.
• Pay for performance incentives: Supplementing core financial incentives with contract support for performance metrics like quality care gap closure related to STAR ratings and AHA visits to enable accurate member health status to be confirmed annually.

Core operational focus on the MA risk adjustment program is of course also required as a component of MA plan management.

Baker Tilly understands the key insights required to drive proactive care plans appropriate for each MA member and how to develop proactive analytics tools to identify and act upon potentially missing diagnosis information. Within the MA space, these insights are key to driving provider and member outreach to schedule in-home or in-office visits to document all pertinent diagnoses and manage members’ health. Baker Tilly knows the importance of the risk-adjusted MA programs and can support your organization’s MA program risk optimization strategy, including:

• Reporting reliability and incentive building: Driving chart chases and accurate coding from providers, and building contract incentives to ensure focus on annual health assessment visits to align CMS reimbursement with member health needs.
• CMS payment modeling: Properly planning for, and modeling, CMS payments, and accounting for any errors that may severely disrupt the ability to accurately forecast financials for the coming year.
• Analytic tools development: Developing analytic tools with business logic to identify undocumented HCCs, leveraging key data points (e.g., historical claims and Rx data), and utilizing VBC incentives to involve providers directly with HCC outcomes and care gap closure. Empowering providers and coordinators with the insights necessary to schedule member visits and ensure all conditions are reviewed and appropriately documented and managed.
• Operational efficiency and provider relationship management: Establishing an approach to provide a comprehensive, standardized, centralized and actionable list of member insights (e.g., risk closure, care gap closure, AHA visits, etc.) to providers without duplicate or contradicting information.

Whether your organization pursues capitated agreements or hybrid VBC/FFS agreements with providers, data management is key to controlling risks and costs while also managing MA reimbursement. Baker Tilly understands the importance of having a comprehensive and sophisticated data management strategy, and can assist health plans with establishing an effective VBC data management platform, including:

• Planning and implementation: Developing a road map that will give health plans (and their network providers, as appropriate) visibility into current and future technical capabilities, and executing road-map-based plans to implement technology that supports the creation of a reliable foundational data set that MA operations can run upon in coordination with other operational capabilities.
• Establishing and maintaining data governance: Establishing data balancing and controls for all data exchanges; defining refresh processes that keep disparate data sources in sync and give users visibility into the timeliness of data available to them; developing and maintaining data lineage and supporting documentation that traces data from the source to all target systems; and establishing and maintaining data user training, user guides and data dictionaries to enable end-user transparency and data comprehension.
• Implementing data security and privacy standards: Defining and maintaining data privacy and security requirements, and ensuring these requirements are well understood across the organization in order to protect sensitive member information as well as provider contracting terms.

Every decision made to define your organization’s approach to MA has an operational impact on the organization and its stakeholders, processes and systems. In order to fully integrate all of the different components of an effective MA program, a handful of targeted projects, or a larger transformation, may be required. Health plans need to consider the impact on employees, members, providers and all stakeholders; implications for processes both inside and outside of the organization; as well as an array of technology implications.

Baker Tilly has experience working with both large and small organizations to establish roles and responsibilities to help companies “bring it all together” from end-to-end. We believe in driving transformations through use of a holistic business architecture with a focus on solution components, whether they are people, process or technology based, and by offering expert advice on whether building, buying new or adapting existing solutions is most effective to meet business needs. We use solution architecture to create delivery plans that leave the organization with an integrated set of components to achieve their business objectives. Whether it’s individual projects to deliver partial capability sets, or a complete organizational transformation to drive program evolution, Baker Tilly has the experience and expertise to serve as a partner on the path to MA excellence.