CHAIRPERSON'S WELCOME & OPENING ADDRESS Sy Zahedi, President MedXM

200 Pages·2016·7.96 MB·English

CHAIRPERSON’S WELCOME & OPENING ADDRESS 
Sy Zahedi, President 
MedXM
Sy Zahedi 
President & Chief Executive Officer 
As the CEO and President of MedXM, Sy brings a unique blend of business development in
the medical industry dating back over twenty-five years. His significant background as an
entrepreneur and experience in expanding distribution channels, instituting new technology
platforms accompanied with developing strategic business and operational plans for new
ventures has placed this company on the forefront of healthcare. It's his belief in patient
education, prevention and early detection accompanied with technology creation, value and
delivery that drives this company into this new era in healthcare.
10 YEARS OF STAR RATINGS: HOW CAN WE LEARN FROM THE PAST AND BUILD FOR THE FUTURE? 
Melissa Smith, Senior Quality Performance and Improvement Consultant 
GORMAN HEALTH GROUP
Melissa Smith is a Senior Consultant with Gorman Health Group (GHG).
She brings over 20 years of healthcare experience to GHG, more than five
of which have been in an operational leadership capacity in Medicare
Advantage and Part D health plans. Melissa has extensive experience
developing strategic and tactical solutions to maximize performance within
quality measurement programs. Melissa also has a strong background of
building productive partnerships across internal teams and with external
vendors, and has successfully worked with independent providers, large
health systems and PBM’s to improve health plan performance on Part C
and D quality measures. Melissa’s unique background of business process,
regulatory compliance, and healthcare quality offers our clients the
opportunity to maximize quality performance and revenues.
6/13/2016
10 YEARS OF STAR RATINGS:
LEARNING FROM THE PAST,
BUILDING FOR THE FUTURE
MELISSA SMITH
SENIOR CONSULTANT
JUNE 27, 2016
WHO IS GORMAN HEALTH GROUP?
Gorman Health Group is the leading solutions and consulting firm
for government-sponsored health programs
Government Programs
Leading enterprise of national consulting services and software solutions for
payers and providers
Our Mission
Our mission, as the industry’s most active professional services consultancy and
provider of technology-based solutions, is to empower health plans and providers
to deliver higher quality care to beneficiaries at lower costs while serving as
valued, trusted partners to government health agencies
Washington, DC
Headquartered in Washington, DC, with more than 200 staff and contractors
nationwide with over 2,000 combined years of Government Programs experience
Leadership
Deep payer and provider knowledge coupled with Centers for Medicare &
Medicaid Services (CMS) regulatory expertise
Privately Owned
Founded in 1996
Copyright © 2016 Gorman Health Group, LLC
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6/13/2016
BROAD SERVICES
Our clients have one-stop access to expert advice, guidance, and support,
in every strategic and operational area for government-sponsored programs, across seven verticals.
CLINICAL
Changing how you approach Medical Management,
Quality and Stars. COMPLIANCE
Offering guidance and support in every strategic and
operational area to ensure alignment with CMS.
PHARMACY
Leading experts in Part D, PBM, formulary
and pharmacy programs.
OPERATIONS
Bringing excellence to every aspect of your
implementation from enrollment to claims payment.
HEALTHCARE ANALYTICS & RISK
ADJUSTMENT SOLUTIONS
Implementing cross-functional risk adjustment
programs for medical trend management and quality
improvement.
STRATEGY & GROWTH
Driving profitable growth and member retention
PROVIDER INNOVATIONS through strategic marketing, sales, and product
Supporting network design and medical development.
cost control implementation.
Copyright © 2016 Gorman Health Group, LLC 3
STAR RATINGS:
BRINGING IT ALL TOGETHER
Membership
Accounting
Star Ratings Risk
Mastery Adjustment
Analytics
Compliance
“Make It Work” Proactive
Care Member Svc. &
Management Support
Collaborative,
Accountable
Providers
Copyright © 2016, Gorman Health Group, LLC 4
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ACHIEVING THE GOAL
2016
2015
2014 AVG STAR RATING
AVG STAR RATING 4.03
3.92
AVG STAR RATING
3.84
Final Year of 40% of MA-PDs 49% of MA-PDs (179
Star Ratings earned ≥4 Stars contracts) earned ≥4
Demo Stars
60% of MA-PD
enrollees are in 71% of MA-PD
contracts with ≥4 Stars enrollees are in
contracts with ≥4 Stars
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ACHIEVING THE GOAL
2016
2015
2014 AVG STAR RATING
AVG STAR RATING 4.03
3.92
AVG STAR RATING
3.84
Final Year of 40% of MA-PDs 49% of MA-PDs (179
Star Ratings earned ≥4 Stars contracts) earned ≥4
Demo Stars
BUT….. 60% of MA-PD
-369 plans were
rated in 2016. enrollees are in 71% of MA-PD
-188 more are on contracts with ≥4 Stars enrollees are in
the chase. contracts with ≥4 Stars
CCooppyyrriigghhtt ©© 22001156,, GGoorrmmaann HHeeaalltthh GGrroouupp,, LLLLCC 6
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6/13/2016
THE GAME IS GETTING TOUGHER
20
4-Star 5
thresholds
increased in
2016 Part D measure
Very little low- average ratings
10
hanging fruit increased
remains
Part C measure
average ratings Noncompliance
increased
1 Star!
Copyright © 2016, Gorman Health Group, LLC 7
IT’S TAKEN 10 YEARS TO GET HERE, BUT…
THE PAST & PRESENT THE FUTURE
2006 2015 2016 2017 2018 2019 2020 2021
MA Star Ratings MA Quality QHP QRS QHP QRS CMS to release Medicare FFS MMC QRS
program created Bonuses paid pilot in 5 implementation to guidance on the merit-based must be
only to high states be completed MMC QRS the incentive implemented
Star-Rated measures & payments
MA plans MMC QRS Inaugural methodologies (MIPS) begin
regulations Medicare FFS for comment
issued MIPS/QPP
measurement
Medicare FFS period begins
QPP created
TRANSFORMATIONAL DEPLOYMENT OF HIGH-ROI QUALITY IMPROVEMENT ACTIVITIES
Copyright © 2016, Gorman Health Group, LLC 8
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6/13/2016
MEASURE UPDATES:
THE AGILITY TEST CONTINUES
7 8 9
1 NEW MEASURES UNDER 1 NEW MEASURES UNDER 1 NEW MEASURES UNDER
0 CONSIDERATION: 0 CONSIDERATION: 0 CONSIDERATION:
2 None 2 Medication Reconciliation 2 Statin Therapy measures
Post Discharge& (Part C and D), potentially
Hospitalizations for Asthmaand Depression
Potentially Preventable measures (Part C)
Conditions
RETIRED MEASURES: RETIRED MEASURES: RETIRED MEASURES:
Improving Bladder Control High Risk Medication TBA
measure to be temporarily measure to be temporarily
moved to Display Page moved to Display Page.
Others TBA
POTENTIIAL UPDATES:
Slight methodology changes POTENTIAL UPDATES: POTENTIALUPDATES:
for several measures. MPF Price Accuracy; NCQA TBA
to evaluate Colorectal
Cancer Screening& Fall
Risk Mgmt based on
USPTF recommendations.
Copyright © 2016, Gorman Health Group, LLC 9
MEASURE UPDATES:
THE AGILITY TEST CONTINUES
7 8 9
1 NEW MEASURES UNDER 1 NEW MEASURES UNDER 1 NEW MEASURES UNDER
0 CONSIDERATION: 0 CONSIDERATION: 0 CONSIDERATION:
2 None 2 Medication Reconciliation 2 Statin Therapy measures
Post Discharge& (Part C and D), potentially
Hospitalizations for Asthmaand Depression
Potentially Preventable measures (Part C)
Conditions
RETIRED MEASURES: Have you upRdEaTtIeRdE Dyo MuEr ASStaUrR REaSt:ings work planR?ETIRED MEASURES:
Improving Bladder Control  Statin ThHeirgahp Ry imske Maseudriceast iroenq uire coordinated TreBpAorting and outreach to
measure to be temporarily membersm &ea psruorvei dtoe rbse atecmropsosr ainritley rnal and PBM teams.
moved to Display Page  Depressimonov mede atos uDriespsl areyl yPaogne e. l ectronic capture of patient-reported
Others TBA
outcomes as calculated through providers’ use of PHQ-9 tool.
 Asthma measures report dispensing of appropriate medications that the
member remained on during the treatment period and the ratio of
POTENTIIAL UPDATES:
Slight methodology changes controllePr mOTeEdNicTaItAioLn Us PtoD tAoTtaElS a:sthma medicatPioOnTsE. N TIALUPDATES:
for several measures. MedicaMtiPoFn sP rbiceec Aocmcuer amcyu;c NhC mQoAr e integratTeBdA via new measures.
Measuremtoe nevt aplueariteo dCso lcooreucltda l begin as soon as 1/1/17 -are you ready?
Cancer Screening& Fall
Risk Mgmt based on
USPTF recommendations.
Copyright © 2016, Gorman Health Group, LLC 10
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6/13/2016
2017 AND BEYOND:
THE STAR RATINGS TARGET IS BROAD
•Care Coordination (Data- Physician-
Driven)
•Post-Discharge Influenced
Medication
Reconciliation* •Asthma Medication
Fill/Adherence
•MPF Price Accuracy •Asthma Treatment •Initiation and
•Reminders for •Depression Care Engagement of
Immunizations, •Hospitalization for Alcohol or Other
Screening Tests, and Potentially Preventable Drug Treatment
Appointments Complications* •Pharmacotherapy
•Reminders to Fill •Statin Therapy Mgmt of COPD
PMreedsiccraiptitoionnss or Take •High Risk Med Updates Exacerbation
•Disenrollment Reasons •Pain Management
•Transition Monitoring •Pharmacotherapy Mgmt Member-
of COPD Exacerbation
Plan- •Reminders for Influenced
Immunizations & Appts
Influenced •Computer Use During
Office Visits
* May be introduced as 2018 Star Measure (based on 2016 services)
Copyright © 2016, Gorman Health Group, LLC 11
EVOLUTION = MEASURING NUANCES
= 2016 5 Star cutpoint
95%
= 2016 4 Star range
= 2016 3 Star range
90%
= 2016 2 Star range
85%
80%
2016 Average:
3.4
75% 2D0o1n5 ’3At .Fv4oe5rraggeet::
Members often
don’t differentiate
70% between Part C &
Part D!
Getting Needed CareGetting Appts & Care QuCiucsktloymer Service Rating of Health Care QRuaatliintyg of Health PlanCare CoordinationRating of Drug PlanGetting Needed Drugs
Copyright © 2016, Gorman Health Group, LLC 12
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