optimizing the success of your care management … · •the overall quality improvement plan and...

APRIL GILLVice President, Analytic SolutionsWelltok

JANE SCOTTVice President, Clinical InnovationsGorman Health Group

OPTIMIZING THE SUCCESS OF YOUR CARE MANAGEMENT PROGRAMS

l CONFIDENTIAL INFORMATION © WELLTOK 2018

SaaS company providing an

enterprise-level, sponsor-branded,

consumer activation platform for the

healthcare industry

WHO ARE WE?

WELLTOK AT-A-GLANCE

WHO DO WE SERVE?

Health Plans

Health Systems

Employers

Health ServicesRetail Pharma

Gov’t Sponsors

WHAT’S THE VALUE?

Enable population health managers

(sponsors) to activate consumers by targeting and connecting them

with personalized health resources

WHAT DO WE DO?

Empower people to become engaged healthcare consumers living at their highest level of well-beingMISSION

• Power growth and retention initiatives

• Impact healthcare cost trend

• Defragment the consumer experience

Copyright © 2018 Gorman Health Group3

OUR DISCUSSION: KEY POINTS TO CONSIDER FOR A SUCCESSFUL CM PROGRAM

Chronic Disease Data

Review of Requirements

Upcoming/New Changes or Influences

Vendor Use/Oversight

Risk Adjustment/Clinical Integration

Care Management (CM) Systems

Staff Education

Diabetes Prevention

Copyright © 2018 Gorman Health Group4www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-

care/decision/mcc/mcc_infographic_printable.pdf

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mcc_infographic_printable.pdf


CHRONIC DISEASE FACTS…FROM THE CDC*

Much of the chronic disease burden is attributable to a short list of key risk factors; most U.S. adults have more than one of these risk factors:

• High blood pressure

• Tobacco use and exposure to secondhand smoke

• Obesity (high BMI)

• Physical inactivity

• Excessive alcohol use

• Diets low in fruits and vegetables

• Diets high in sodium and saturated fats

https://www.cdc.gov/chronicdisease/overview/index.htm


FRAMEWORK FOR A SUCCESSFUL PROGRAM


WHAT IS REQUIRED?

QI Program Annual Evaluation

• CM Annual Evaluation

Quality/Program Evaluation for Special Needs Plans (SNPs)

Model of Care (MOC) Annual Evaluation for SNPs

Recent SNP/MOC Audits/Corrective Action Plans (CAPs)

• CAPs continually integrated and measured for ongoing performance

• System changes/ process changes effectuated

First-Tier, Downstream, and Related Entity (FDR) Oversight of Any CM Vendors

State/Medicaid Contractual Data/Reporting


ARE YOU MEETING THE QI PROGRAM REQUIREMENTS?

Medicare Advantage Organizations (MAOs) are required to address the following seven components as part of their Quality Improvement (QI) Program:

1. Chronic Care Improvement Programs (CCIPs); successful interventions?

2. Quality Improvement Projects (QIPs) should be part of your ongoing QI/CM program

3. Develop and maintain a health information system

4. Encourage providers to participate in CMS and HHS quality improvement initiatives;

how do you communicate these to your provider network?

5. Contract with an approved Medicare CAHPS® vendor/conduct CAHPS®

6. An annual program review process for formal evaluation of the QI Program

that, at a minimum, addresses the QI Program’s impact and effectiveness and

7. Corrects problems for the plan


Integrate into your CM Program:

• Audit Requirements

• State Reporting Requirements

• System Requirements

• Model Document Templates

MEDICARE-MEDICAID PLAN (MMP) QUALITY REQUIREMENTS


CCIP COMPONENTS = CM PROGRAM DESIGN

Engage enrollees as partners in their care

Increase disease management and preventive services utilization

Improve health outcomes

Be universally applicable to MAOs

Facilitate development of targeted goals, specific

interventions, and quantifiable, measurable outcomes

Guard against potential health disparities

Produce best practices

Don’t reinvent the wheel!This Photo by Unknown Author is licensed under CC BY-NC-SA

https://mimajestad.blogspot.com/2009/01/psicologia-basica-1.html

https://creativecommons.org/licenses/by-nc-sa/2.5/


PROGRAM DESIGN AND EXECUTION CHALLENGES

Cost Savings

Opportunities for program design and optimization are not

clear, resulting in underutilized resources

and inefficient spend

Engagement Insight

Lack of insight into who’s engaged, how they want to be engaged and those

who can be the most impacted

Crowded Ecosystem

With disparate point solutions, it’s difficult to

understand which programs will perform, meet

population needs and who’s receptive to them


Program success is influenced by many factors:

• Health status

• Utilization patterns• Comorbid conditions• Adherence• Prescription use patterns• Acute events

• Consumer profile & social determinants

• Family status• Financial status• Transportation and access to care• Purchasing and consumer behavior• Communication and engagement patterns

Even the best care management programs can fail without a smart engagement and incentive strategy

REMEMBER ONE SIZE DOES NOT FIT ALL


QualityDriving the highest impact on HEDIS and Star measures.

Care ManagementReduce likelihood of recurring medical issues,

disease progression and avoid hospital admissions/readmissions.

CREATE VALUE BY TRANSLATING PREDICTIVE INSIGHTS INTO CONSUMER CENTRIC ENGAGEMENT


QualityDrive the highest impact on HEDIS

and Star measures.

Acquisition and RetentionIdentify members for acquisition,

retention, loyalty programs, and power onboarding.


PharmacyPersonalized and impactful outreach

for medication adherence.


CMS/NCQA REQUIREMENTS FOR SNP CM

The organization must develop a MOC quality performance improvement plan that describes:

• The overall quality improvement plan and how the organization delivers or provides for appropriate services to SNP beneficiaries, based on their unique needs.

• Specific data sources and performance and outcome measures used to continuously analyze, evaluate, and report MOC quality performance.

• How its leadership, management groups, other SNP personnel and stakeholders are involved with the internal quality performance process.

• Describe how the SNP-specific measurable goals and health outcomes objectives are integrated in the overall performance improvement plan.


QUALITY/PROGRAM EVALUATION FOR SNPS

The goal of performance improvement and quality measurement is to improve the SNP’s ability to deliver high-quality healthcare services and benefits to its SNP beneficiaries.

Achievement of this goal may be the result of increased organizational effectiveness and efficiency through incorporation of quality measurement and performance improvement concepts that drive organizational change.

The leadership, managers, and governing body of a SNP organization must have a comprehensive QI Program in place to measure its current level of performance and determine if organizational systems and processes must be modified, based on performance results.


RECENT/UPCOMING CHANGES

2019 Call Letter

2019 Audit Protocol for Comment…make sure you comment if needed

21st Century Cures Act*: Begin to think about how to apply requirements of the Cures Act to your own quality/clinical and provider network initiatives

Medicare Diabetes Prevention Program – CDC program design

Comprehensive Addiction/Recovery Act (CARA) – Revise your CM Program

*Summary-https://www.congress.gov/bill/114th-congress/house-bill/34


2019 CALL LETTER

Case/Care Management Programs will require a stronger design to support opioid/drug management:

• Performed with beneficiaries’ prescribers aimed at coordinated care

• Closer monitoring of CM population

• CMS expects plans to report back to us their results of implementing the review and case management policies through the Overutilization Monitoring System (OMS)

• Your CM system will need to have edits in place to identify potential risk and incorporate appropriate interventions which can be measured

Does your CM system support these changes? System reporting capability?


2019 CALL LETTER

Disaster Case Management

The Adult Immunization Measure for Star Ratings – CM System Data/ Registries

“Enhanced Disease Management (EDM) services in a supplemental EDM benefit would include qualified case managers with specialized knowledge about the target disease(s)/condition(s), educational activities that are focused on the target disease(s)/condition(s), and routine monitoring applicable to the target disease(s)/condition(s). The benefit may be proposed as a supplemental benefit in an MA plan’s bid and submitted plan benefit package.” —9


2019 AUDIT PROTOCOL FOR COMMENT – CMS IS CHANGING THE MOC AUDIT PROCESS IN A BIG WAY!

New universe construction – is your system ready?

Describe your organization’s internal system utilized for tracking Health Risk Assessments (HRAs), Individualized Care Plans (ICPs), and Interdisciplinary Care Team (ICT) decisions and activities.

Explain any routinely observed barriers to care when conducting the HRA. Please elaborate on any work-around processes to those barriers.

Does your organization use an acuity scoring system?

• If yes, please describe your organization’s enrollee risk stratification levels and your process for assigning enrollees to a risk stratification level. Provide the level/score in the universe.

Describe the internal system utilized for ensuring ICTs are comprised of appropriate disciplines, as described in the MOC, and ICTs coordinate care and communicate with each other and enrollees regarding the ICP.

Detailed explanation of the MOC-specific measurable goals, enrollee experience, and health outcome objectives that are evaluated, any benchmarks and rationale, and data gathering/ monitoring methods (e.g., HRA timeliness, which metrics are used, what data/reports are utilized to evaluate and monitor performance, and who/which personnel/operational area(s) were involved).


CURES ACT: ARE YOUR PROGRAMS & SYSTEMS PROGRAM-READY TO SUPPORT THE ACT?

Sec. 17006. Allowing End-Stage Renal Disease (ESRD) beneficiaries to choose a Medicare Advantage (MA) plan:• This section eliminates the prohibition against individuals with ESRD from enrolling in an MA

plan after they have developed ESRD, effective for plan years beginning on or after January 1, 2021. Also beginning with plan year 2021, it transfers responsibility for the costs of acquiring organs for kidney transplants from MA plans to the fee-for service portion of Medicare. Payments to MA plans will be adjusted to reflect that shift.

PY 2018 - Healthcare providers must be enrolled in Medicare to provide services to Medicare beneficiaries: Delegated vendor compliance?

• Any time a healthcare provider or supplier fails to meet CMS enrollment requirements or violates certain federal rules and regulations, CMS may revoke the provider or supplier’s enrollment and prevent them from billing Medicare Part A or Part B and from prescribing Part D drugs.

• Final rule also prevents MA plans from making payments to individuals or entities that have been excluded by the Office of Inspector General or have been revoked by the Medicare program, regardless of whether that provider or supplier is out of network.


Conduct an annual evaluation of your/vendor’s system reporting suite to ensure alignment with:

• Test your universe accuracy no less than quarterly

• Measurement of clinical outcomes capability

• Integration of PDE data:

Identifying high risk/chronic use members for drug/opioid programs

• Measurement of care gap closure/ volume of goals met per care plan

• Quality measures; include state-required for FIDEs/SNPs

• HEDIS®/Population Health – NCQA accredited plans

• Member engagement measures –reason codes/trending/reporting

• Integrate updated provider directories

• Identify access to care issues

• Trigger “clinically” timely information sharing or education

SYSTEMS You Need Excellent System Reporting, Especially If You Use A Vendor!


EFFECTIVELY COORDINATING BENEFITS

MLTSS

Mental Health Services

(specifically on dual members)

TransportationCommunity-

Based Services

DME or Other Supportive

DevicesVA Programs

Retiree Programs

Transitions for Duals from

Solely Medicaid


PATIENT SAFETY/FALLING

Fear of falling equals a “risk” and can lead to avoidance of activities, which creates isolation = barrier to care

The danger is that members may become more sedentary, which leads to decreased physical conditioning, which, in turn, can actually increase risk of falls

In addition to decreased physical activity, a person with a fear of falling may also experience:• Anxiety • Depression with walking and balance • Use of a walking aid • Problems as a walker or cane • Reduced quality of life • Social isolation

Use your care managers, UM/discharge planners, and your providers to look at the “risks” and other potential issues that contribute to barriers of care


INTEGRATE RISK ADJUSTMENT

Why does risk adjustment affect your CM Program?

• Risk adjustment score vs. CM system stratification score

Using a vendor for home evaluations or post-acute follow-up:

• Integrate the wealth of information from the evaluation form into the CM system

• Ask for data feed or PDF for care plan integration

• Compare diagnosis captured to those reported on the HRA/identified in the current care plan

• At the very least, capture the mental health/safety and social determinants data/risks


Re-evaluate your population as per MOC 1 as part of your annual evaluation (even if you are not a SNP)

Diabetes, CHF, COPD, Back Pain:

• Identify the members with these disease states and the providers who serve them to conduct targeted education/access/benefit usage…saves overall cost

• UM/Claims quarterly/mid-year reporting to monitor outcomes/trends

Bladder Control for Star Ratings

• Post-stroke patients

• Post-hysterectomy patients

• Mine pharmacy claims to identify members for targeted educational material

Use your complaints/appeals and adverse organization determinations to help you decide what supplemental benefits to consider for 2019

POPULATION MANAGEMENT IS KEY TO SUCCESS WITH PROVIDING VALUE-BASED CARE

(Value Is Calculated by Dividing the Outcomes of the Care by the Costs of the Interventions)


HEALTHCARE DATA ALONE DOESN’T TELL THE WHOLE STORY

90%

Under the current “sickcare” system, most of what is known about individuals is retrospective from claims and clinical data.

Without consumer data, you may be effectively missing 90% of the available information about your members that helps you better understand, motivate and activate them.

10%


OPTIMIZE YOUR SPEND AND RESOURCES AND GET PERSONAL

Personalized Experience

Who is Impactable? By What Means?Who Has What

Needs or Interests?


Plans cover MDPP services in accordance with the MDPP regulations:

• Must consist of structured health behavior change sessions that are furnished under the MDPP expanded model with the goal of preventing diabetes among Medicare beneficiaries with pre-diabetes and that follow a CDC-approved curriculum.

Plans may also offer additional MDPP-like services as a supplemental benefit.

MEDICARE DIABETES PREVENTION PROGRAM (MDPP)


Use Case – Gaps in Care

1. Identify population based on clinical risk2. Define objectives and constraints such as time or budget3. Leverage advanced analytics to prioritized those most receptive to specific channel and message for

outreach

The Consumer View - Pursuing a Greater Opportunity for Impact

Improvement in effectiveness by identifying

members likely to be receptive to IVR intervention

More people received the message about diabetes care and prevention for every 25k individuals targeted.

23K

Targeting Mechanism TargetedReceptivity

Rate3 Total ReceptiveEstimated

Impact Rate2

Total

ImpactedValue1

Outreach without prioritization 200,000 22.00% 33,000 30% 9,900 $ 1,059,300

Outreach Results using

Welltok Analytics200,000 37.50% 56,250 30% 16,875 $ 1,805,625

Difference 0 15.50% 23,250 0 6,975 $ 746,325

$746k Additional medical cost savings 70%

1) Estimated savings based on $107 per member savings identified in ADA study of claims costs for patients in a diabetes program versus those not in a program. Source: http://care.diabetesjournals.org/content/25/4/684.short

2) Estimated impact rate based on Welltok book of business.3) Receptivity rate based on IVR findings in Welltok study. Does not include mail receptivity.

http://care.diabetesjournals.org/content/25/4/684.short


PROVIDER SUPPORT: CHRONIC CARE MANAGEMENT (CCM) SERVICES BILLED

CCM reimburses physicians under CPT® code 99490 for providing non-face-to-face care coordination services to eligible Medicare patients with two or more chronic conditions.

The CCM program allows providers to proactively manage chronically ill patients’ health outside the normal office setting and be reimbursed for those services, which have typically been provided without compensation.

Integrating CCM into your network, CM Program, and overall strategy can assist with:

• Improved provider engagement/support to the overall CM Program goals

• Reducing high readmission rates

• Overall utilization costs

Physicians and non-physician practitioners may bill CCM services:

• Certified Nurse Midwives

• Clinical Nurse Specialists

• Nurse Practitioners

• Physician Assistantshttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf


Track Provider Performance Against Specific OutcomesPROVIDER SCORECARDING

Dynamic, multi-dimensional view of quality, clinical and financial impacts at the payer, group and provider-level.

Key Metrics• Quality Rating• Risk Score• Medical Loss Ratio• Chronic Condition

Retention

Bringing measures of provider performance together and creating a singular view allows you to identify training and network management opportunities across the spectrum.


TELEHEALTH


USING A VENDOR?

For administration of the HRA and/or Care Management:

• Conduct initial and ongoing due diligence

• Measure/review and collaborate on member engagement performance monthly

• Conduct no less than monthly review of the performance reporting

• Conduct no less than quarterly performance review of script compared against live/call recordings

• Consider conducting member satisfaction surveys with just the HRA process

• Ask for and review no less than monthly the overall care plan process/goals/ outcomes


Are flexible and transparent

Built to solve your unique challenges

Can be built and tested in real-time

Easily update, calibrate and run on demand

Custom Predictive ModelsUse Proprietary Algorithms to Get the Most Accurate AnalysisDEPLOY CUSTOM, DYNAMIC PREDICTIVE MODELS


A clear view into the process ensures you can have confidence in the outcomes.

FOCUS ON TRANSPARENCY

0

0.5

1

1.5

2

2.5

3

1 2 3 4 5 6 7 8 9 10

Model Strength

Average

Model Accuracy

Model Predictors


INTEGRATION OF MENTAL HEALTH/SOCIAL DETERMINANTS

Program Components

• Nutrition/meals is the leading community or supportive service linked to Social Determinants of Health (SDOH) interventions.

• Consider offering healthcare system navigation assistance to members with SDOH limitations.

• Implement SDOH risk score and conduct reassessments more frequently.

• Develop or partner with a community resource for violence identification/ education and prevention program.

• Consider revising your HRA based on your no less than annual re-evaluation of your target population outcomes.


ADVANCED ANALYTICS BRINGS THE DATA TOGETHER

ENHANCED BENEFICIARY INFO

MEDICAL RECORD

CLAIMS

VOTING

TAXES

DEMOGRAPHICS

FAMILY

BUYING HABITS

EDUCATION

• Voter status, affiliation, activity• Household and family composition• Income and tax status• Property ownership; home, auto,

sensitivities, and preferences• Credit/debt information• Online presence• Social media activity• Wealth status

Proprietary Database 275M+ Americans

800+ Variables

CONSUMERFEEDBACK

ACTIVITY COMPLETION

CONSUMERMOTIVATIONS

CONSUMERINTERESTS

STATE OF THE MARKET WELLTOK PROPRIETARY DATA


FINANCIAL

Age

Family Status

Ethnicity

Language Spoken

Education Level

Access to Care

Proximity to ER or PCP

Potential Health Risks

Access to Parks, Hiking or Biking Trails

Access to and/or Utilization of Public Transportation

Seasonal Weather Patterns

CLINICAL

Spender or SaverOwn or Rent HomeInvestorOffered CreditIncome Level

Response to Product Offers

Response to Different Types of Communications

Types of Transportation Used

Sensitivity to Changes in Price

Health RiskProvider

PrevalenceCompliance

PurchasingWealthSpending

DemographicsPsychographics

Education

ReceptivityBehaviorLifestyleSensitivityCONSUMER INDIVIDUAL

ENVIRONMENTAL

WeatherTransportationParks & Trails

SpenderMakes <$50,000/year

Rents homeMay need educational and financial support

to understand resources

46 yo Hispanic maleSpeaks English but

prefers Spanish Caregiver – single father

and mother lives in home

Did not graduate HS9th grade reading level

No social media Receptive to phone and

text, never emailUses public transport

Access to nutritious foods and health care is limited2 fast food places nearby

Needs telephonic coaching

Closer to an ER; more likely to use ER

frequently At-risk for

hypertension, high cholesterol and asthma

Lives near a parkOpen to step program to spend time w/ kidsHigh pollen counts in

spring drive ER use

INDIVIDUALLY-IDENTIFIABLE DATA REVEALS THE FULL STORY OF JACK


DRIVE MEMBERS TO THE RIGHT PROGRAMS AT THE RIGHT TIME

PRE-ACUTE/

POST-ACUTECHRONIC

CONDITION MANAGEMENT

DIGITAL HEALTH PROGRAM FOR KIDS



PREVENTIVEGENERAL HEALTH AND WELLBEING

GAPS IN CARE


EDUCATION TO CM STAFF

Coordination of benefits – especially Medicaid plans

Coordination of VA benefits and information

Identification of barriers through member use of outside services such as:

• MTM Program – CM interventions to support current program

• A family member to cook

• OTC substitution

• Causes of isolation

• Scripts for engagement

Opioid program

• Identification of vulnerable, high-risk members

Pain Management – Clinical Guidelines

Community Resources


Admission criteria

Outreach and engagement process

Outreach data tracking

Multi-media outreach – system capabilities

RE-EXAMINE YOUR CM ENROLLMENT PROCESSES


BRIDGE THE GAP BETWEEN EXPECTATION AND EXECUTION

Healthcare – insurers and providers – falls short in delivering what consumers expect.

Source: Accenture analysis, Accenture 2015 Global Consumer Pulse Research, Accenture 2015 Health Consumer

Health insurers fall short of

other industries in digitally

engaging consumers.

US

MARKET

100

Health Care Providers

P&C Insurance

Wireless

23 25 31

Average

34

Health Insurers

36

Utility, Consumer Electronics

37

Retail-Books/Media

39

Hotels & Lodging

45Digital

Intensity

Banking

38

Insight Driven Health


ENGAGE MEMBERS WITH A MULTI-CHANNEL APPROACH

LIVE AGENT

SMS/APP

WEB

IVR

EMAILMAIL @


DO YOU KNOW YOUR CHALLENGES?

Operational challenges/metrics

• Do your adverse organization determinations or appeals categories provide clues to your CM Program?

Provider network challenges

• Ensure access issues and out-of-area utilization are measured through the CM Program

System challenges

Leadership challenges

Staff challenges

Engagement challenges –Rewards and Incentives!

• Members

• Providers

• Completion of needed HRA information

• Agreement to participate in all programs appropriate


MAKE AN IMPACT WITH PROVEN METHODS

Men Need a Nudge Use the Right Voice

Time Your Call Just RightSecond Chances Work

Data proves it: men respond positively when they are given a gentle reminder to schedule a prostate screening

Screening completions improved 89% for Hispanic men when they were messaged in a male voice

Contacting seniors at 3pm on weekdays is 2x more effective than at noon

A simple “are you sure?” works to convert enrollment into condition management programs


MEMBER FATIGUE IS REAL


AVOID BURNOUT AND MESSAGE CONTENTION WITH COORDINATED OUTREACH

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Chronic Condition Management

Gaps in Care

Flu Express Outreach

Satisfaction Survey

Prevention & Screenings Outreach

CAHPS Message

Medication Adherence

CAHPS/HOS Survey &

Education

Prevention & Screenings Outreach

Gaps in Care

Gaps in Care

High-Risk Outreach and Messaging

Ongoing Quality Improvement Targeting and Strategy Outreach

Post-Hospital Discharge, Readmissions


USE INDUSTRY RESOURCES* FOR GUIDANCE:

Track chronic diseases and their risk factors and share the information in easy-to-use formats.

Ensure coordination among multiple data systems, including behavioral risk factor surveys (e.g., the Behavioral Risk Factor Surveillance System), birth and death certificates (from the National Vital Statistics System), registries of cancer cases and deaths (e.g., the National Program of Cancer Registries), and healthcare data (e.g., from Medicare data sets).

Monitor social and environmental factors that influence health, as well as policies that affect chronic diseases, such as those related to smoke-free air, access to healthy foods, and community water fluoridation.

Conduct surveillance of healthcare preventive services, such as cancer screening, the “ABCs” of heart disease and stroke prevention (aspirin use, blood pressure and cholesterol control, and smoking cessation), and measures of diabetes control (e.g., hemoglobin A1C) and obesity (e.g., BMI).

Leverage health information technology to improve efficiency and timeliness of public health surveillance (e.g., use new U.S. meaningful-use standards to speed reporting to state cancer registries).

*CDC, AHRQ, KFF


USE INDUSTRY RESOURCES* FOR GUIDANCE:

Community-Clinical Links in Action

• Increase the use of effective community interventions—such as chronic disease self-management programs, the National Diabetes Prevention Program, and smoking cessation services—by making them widely available, ensuring doctors refer their patients to them, and helping to ensure they are covered by health insurance.

• Link existing public health services, such as tobacco quit lines, to healthcare systems.

• Establish partnerships with hospitals and healthcare providers to improve community and population health through use of community benefit investments and advocacy.

• Encourage a broader spectrum of healthcare workers—including pharmacists, patient navigators, and community health workers—to help people manage their own health.

• Use education and outreach to more fully engage the public in its own healthcare.

*CDC, AHRQ, KFF


1 2 3 4 5 6 7 8 9 10

1 2,842 2,471 1,892 3,321 2,453 2,109 3,056 1,879 2,567 2,410

2 2,471 1,892 3,321 2,453 2,109 3,056 1,879 2,567 2,410 2,842

3 1,892 3,321 2,453 2,109 3,056 1,879 2,567 2,410 2,842 2,471

4 3,321 2,453 2,109 3,056 1,879 2,567 2,410 2,842 2,471 1,892

5 2,453 2,109 3,056 1,879 2,567 2,410 2,842 2,471 1,892 3,321

6 2,109 3,056 1,879 2,567 2,410 2,842 2,471 1,892 3,321 2,453

7 3,056 1,879 2,567 2,410 2,842 2,471 1,892 3,321 2,453 2,109

8 1,879 2,567 2,410 2,842 2,471 1,892 3,321 2,453 2,109 3,056

9 2,567 2,410 2,842 2,471 1,892 3,321 2,453 2,109 3,056 1,879

10 2,410 2,842 2,471 1,892 3,321 2,453 2,109 3,056 1,879 2,567

FOCUS ON IMPACT NOT JUST RISK

• Members at highest risk for non-adherence and most likely to be impacted by a live program would be targeted by Program A

• Members at highest risk for non-adherence and likely to be impacted by a live program would be targeted by Program B

• The remaining members at highest risk for non adherence would be targeted by an automated call Program C

Composite likelihood of being receptive/impacted by a live program

Co

mp

osi

te li

ke

lih

oo

d o

f b

ein

g n

on

-a

dh

ere

nt

FINDINGS


Targeting Mechanism

Monthly Target

(N)

Engaged Rate

Engaged(N)

Impact Rate

Impacted (N)

Client Targeting 2015 Experience

50,000 35% 17,512 65% 11,380

2016 Results using Welltok Deciles 1-4

50,000 40% 20,074 89% 17,805

Difference 0 5.0% 2,562 24% 6,425

FOCUS ON IMPACT NOT JUST RISK

Risk/NeedReceptivit

yImpact

Improvement in engaged rate

Improvement in program impact

Decrease in cost per impacted member36%

24%

5%

RESULTSVALUE


Gorman Health Group (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance

Exchange opportunities. Since 1996, our unparalleled teams of subject matter experts, former health plan executives, and seasoned healthcare regulators have been providing strategic,

operational, financial, and clinical services to the industry across a full spectrum of business needs. Our mission is to empower health plans and providers, through a compliant, member-centric

focus, to deliver higher quality care to members at lower costs while serving as valued, trusted partners.

Further, our software solutions have continued to place efficient and compliant operations within our clients’ reach. Our Valencia™ software provides rigorous, compliant, and transparent

workflow controls that ensure your operational processes – and the resulting payment– are as accurate as possible. Sentinel Elite™ is our module-based software solution designed to assist

government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Our Online Monitoring Tool™

(OMT) is the complete Medicare Advantage and Part D compliance toolkit, designed to perform ongoing monitoring and auditing, manage regulatory notices, document corrective actions, and

streamline member material review. CaseIQ™ brings clarity to appeals and grievances and offers a new way to ensure your cases come to a compliant resolution. We also offer training courses

on a variety of industry topics designed to meet the unique needs of your organization through Gorman University™, and our exclusive daily digest, The Insider, provides in-depth analysis and

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We are your partner in government-sponsored health programs.

T

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CONTACT

Jane Scott

Vice President of Clinical Innovations

520-885-3843

[email protected]

April Gill

Vice President, Analytic Solutions

781-202-9163

[email protected]

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optimizing the success of your care management … · •the overall quality improvement plan and...

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