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Raising the clinical bar

Raising the clinical bar. Mark r Dambro, MD CMO, CenseoHEalth , LLC. April 3, 2012. What are we talking about?. CMS pressing for increase in clinical relevance and value ( Quality – Value proposition) Shift focus to the current year Member targeting Importance of focus

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Raising the clinical bar

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  1. Raising the clinical bar Mark r Dambro, MD CMO, CenseoHEalth, LLC April 3, 2012

  2. What are we talking about? • CMS pressing for increase in clinical relevance and value ( Quality – Value proposition) • Shift focus to the current year • Member targeting • Importance of focus • Post evaluation impact

  3. Increasing clinical relevance and value • Manual processes soon to be inadequate • Falling premiums and increasing demands on quality require operational efficiency; stomp out waste • Berwick’s legacy: • Risk adjustment • Value-based purchasing

  4. Value = Quality / Cost • Value • Quality • Cost Porter ME. What Is Value in Health Care? N Engl J Med; 363:2477-2481. Dec 23, 2010.

  5. Quality MA outscored FFS on 9 of 11 measures Guram JS, Moffit RE. TheMedicareAdvantageSuccess Story – LookingBeyondtheCostDifference. NEJM 366;13 March29, 2012

  6. Optimizing Stars • Stars cross entire member population • Only 35% of Stars are derived from HEDIS • Only 4 and 5 Star rated plans will receive a bonus in 2015 • Weighting changing the game • 4 Part D measures weighted as heavily as all HEDIS measures • The highest weights are clinical (5/6 Domain 4 are weighted a 3 and include high risk meds, diabetes treatment, and 4 Part D medication adherence measures)

  7. Shift focus to the current year • Accurate diagnostics maximize revenue • Build a plan to impact care now • Move audits into year of service for maximizing benefit

  8. member targeting Specificity and accuracy • Pick the right members to evaluate; in terms of both risk adjustment and clinical value • Each functional unit will bring a different priority to the table; find some middle ground early on • Establish priorities; financial, clinical, member satisfaction, PCP satisfaction, risk management, disease management. • They’re all important! Avoid a winner takes all attitude here; share the wins and the losses.

  9. Population focus Diagnosis and needs of the chronically ill • Diabetes • Chronic kidney disease (CKD) • Depression, heart failure, neurofibromatosis, drug dependence, aortic aneurysm, COPD, paraplegia, quadriplegia, ostomies, skin ulcers, chronic bronchitis, respiratory insufficiency, paralysis agitans, ESRD, cachexia, amputation

  10. Post-evaluation impact What happens after the in-home evaluation? • CAHPS benefit • Health plan marketing • Gap closure & compliance • Utilization rates • ER • Hospital admissions • Critical care • Office care

  11. Summary • Shift focus to the current year • Address specificity and accuracy in targeting member selection • Focus on those members most likely to benefit • Consensus is good • Measure and expect benefits after the Risk Adjustment event

  12. News, updates, and thought leadership at Censeohealth.com/blog Mark R Dambro, MD 972.715.3820 Chief Medical Officer mdambro@censeohealth.com

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