Latest / Becker’s Healthcare Digital Health + Health IT / Conquering the Cosmos: Mastering the Quest for 5-Star CMS Ratings with Daniele Chenal

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Conquering the Cosmos: Mastering the Quest for 5-Star CMS Ratings with Daniele Chenal · Becker’s Healthcare Digital Health + Health IT

• 0:00
  - Hello everyone.
• 0:01
  I'm Brian Zimmerman with Becker's Healthcare.
• 0:03
  Thank you for joining us for this podcast Today,
• 0:05
  we're thrilled to be joined by Danielle Schal,
• 0:08
  president Command Business Partners, inspire Innovations.
• 0:12
  Danielle, thank you so much for being here.
• 0:14
  - Yeah, thank you. I'm also thrilled to be here.
• 0:17
  - Uh, it's great to have you.
• 0:18
  And of course, we're gonna discuss some best practices and,
• 0:21
  and pragmatic approaches to achieve
• 0:22
  and maintain a CMS five star rating.
• 0:25
  So, with that, let's dive in here
• 0:27
  and just to, to, to lay the groundwork for,
• 0:29
  for the conversation to come
• 0:30
  to help listeners appreciate your perspective.
• 0:33
  Can you just introduce yourself a bit further and,
• 0:35
  and share a bit about your, your role,
• 0:36
  professional background, uh, the work you're doing
• 0:39
  with Inspire Innovations?
• 0:40
  - Yeah, sure. Thanks. Um, yeah, so, um,
• 0:44
  for several years I was a CIO, uh, of a home health agency
• 0:47
  and New York based health plan.
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  I also worked for a business process management software
• 0:52
  company and consulting company for over 10 years
• 0:55
  before I started Command Business Partners in 2012.
• 0:59
  Um, and I've pretty much worked on everything from small
• 1:03
  scale process improvement projects, like transforming
• 1:06
  and automating complaints, appeals
• 1:08
  and grievance processes for a small 20,000 member plan, um,
• 1:12
  to really large scale global
• 1:14
  process standardization projects.
• 1:16
  I spent a number of years, um, working on a project
• 1:19
  for MetLife's Central Europe and Middle East operations.
• 1:23
  Um, today my company, which is Command Business Partners,
• 1:26
  along with my partner company, um, I'm a director
• 1:29
  with Inspire Innovations.
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  Um, we work with our health plan clients
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  to provide a variety of process improvement, optimization,
• 1:38
  and automation solutions.
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  Um, and those solutions help, you know,
• 1:43
  alleviate the staffing challenges that companies are facing.
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  Uh, of course reduce costs, um, but also improve member
• 1:49
  and provider experience and overall operations.
• 1:53
  Um, which as you know, directly impacts star ratings.
• 1:56
  - Yeah. A a absolutely have a direct
• 1:59
  correlation there for sure.
• 2:00
  And, and of course, those star ratings,
• 2:02
  those CMS star ratings carry, carry a lot of weight
• 2:04
  for both payers and providers.
• 2:06
  Mm-Hmm. , um, and Danielle, in,
• 2:07
  in your view here, what are, you know, sort
• 2:09
  of the key factors healthcare leaders should be considering
• 2:12
  as they strive to achieve that five star rating?
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  Mm-Hmm. , um, what,
• 2:16
  what approach do you recommend here?
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  What, what's been your experience?
• 2:19
  - Yeah. Such a key question, really.
• 2:21
  Um, so I think that, you know, it, to summarize it,
• 2:24
  it's definitely, you have to have a long-term strategy while
• 2:27
  you take immediate, you know, near term action, right?
• 2:31
  And so maybe let me elaborate on that a little.
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  So with achieving five stars, right, A lot
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  of times the approach is to analyze the various measures,
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  determine where you are and where you have to be, right?
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  And then focus initiatives to meet each of those measures.
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  I think part of the challenge with just kind of a,
• 2:51
  a near term measure by measure approach is kind
• 2:54
  of like playing whack-a-Mole , right?
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  You know, stars is a moving target.
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  CMS will remove measures, they will replace them
• 3:02
  with different measures.
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  The weightings shift, sometimes it, you're dealing
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  with medical outcomes having heavier weighting than member
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  experience, and that shifts back and forth.
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  Um, and things like the cut marks
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  or the benchmarks you have to achieve are
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  continuously changing.
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  So I think that, again, while you have to have
• 3:19
  that immediate near term focus of dealing with each measure,
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  I think that you also have to, you know, combine that
• 3:26
  with this long-term strategic focus on operational
• 3:30
  excellence and a company wide understanding
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  and commitment to stars.
• 3:36
  - Yeah. And Danielle, quick follow up for you.
• 3:38
  There, you, you, you laid out pretty, uh, pretty succinct,
• 3:42
  but pretty detailed in terms of how CMS star ratings,
• 3:45
  how these are sort of moving targets, right?
• 3:47
  Mm-Hmm. , um, is, is, is there sort of a way
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  to, because I imagine, you know, we at Becker's are, are,
• 3:52
  um, well aware of sort
• 3:54
  of some Friday afternoon CMS
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  updates from time to time .
• 3:58
  Um, so how, how they'll roll those out.
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  Um, but is there, I guess my, my question is, is there a way
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  to really try to get out in front of some of the trends?
• 4:06
  And I'm sure there that's true to an extent.
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  Like you can, um, see some changes coming down the road,
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  but then other things, other elements of
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  that moving target are harder to predict.
• 4:14
  Yeah, for sure. Um, can, can,
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  can you just share a little bit of insight about how
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  that predictive element of this might work?
• 4:21
  - Yeah, I think, I think it kind of goes back to, uh,
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  I think rather than trying to predict
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  how a measure's gonna change, my philosophy is
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  that if you're focused on operational excellence
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  and you're focused on achieving
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  that excellence across the board all the time, right?
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  And the whole organization is focused on, uh,
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  medical outcomes and member and
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  and provider experience, it becomes less a question
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  of where's the target moving, right?
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  You're not as focused on trying to hit a specific target
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  as much as you are just having a broad
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  strategy, if that makes sense.
• 4:59
  - Yeah. Yep. No, that, that, that does make sense.
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  And so just thinking about that excellence then, is
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  that sort of that element would you say?
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  Because, 'cause my next question is really
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  how can leaders at at payer organizations embed these
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  best practices Mm-hmm.
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  in their teams for,
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  for this quality improvement?
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  And I imagine that that commitment
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  to e excellence is a part of your answer.
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  Absolutely. Are there any more specific,
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  are there any more specific examples you can share there?
• 5:21
  - Yeah, for sure. I think so.
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  You know, and probably people have heard this all the time,
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  but I really do think it, it, it matters.
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  People process technology, right?
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  Those are the three things you always have to focus on.
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  And with stars, I think it has to start with people.
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  Um, I was recently at a Becker's conference
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  and, uh, there was a woman speaking from UPMC,
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  and I couldn't agree with her more completely in that
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  what she was talking about was organizations have to,
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  from top to bottom, you know,
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  make sure everyone in the organization understands
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  what stars is, why it's important.
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  Um, and you, I think mentioned earlier, you know,
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  it has a huge impact on revenue.
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  Um, and so each department, each person really has
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  to understand their role in it.
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  Um, and so I think there are some things, you know, it has
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  to kind of become part of the DNA
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  of a, of a culture of a company.
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  Um, and I think that, you know,
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  companies can do things like, you know,
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  make sure every executive
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  and manager knows what the measures are, um, have workshops,
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  um, to educate people, um, make sure you have a champion,
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  um, that understands not only medical outcomes, which is,
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  you know, quality is a big part of it, but so is member
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  and provider experience
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  and, you know, look at ways to maybe reward
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  and incent individuals, teams, managers, and so on.
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  Um, and then the second part of that, of course, goes back
• 6:42
  to then process and technology, um, right.
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  Uh, and making sure that you re-look at those processes
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  that directly impact stars.
• 6:51
  - Yeah. Yeah. And, and so thinking about those processes
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  and technologies, I, I guess my question then is
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  what strategies or resources do you think
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  are really effective at, at improving those processes
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  as it re relates to, of course,
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  achieving that five star rating?
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  Yeah. Um, any specific success stories to call out here?
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  - Yeah, I guess, um, I would say that, you know, first
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  and foremost, I, I love this saying you have
• 7:13
  to slow down to speed up.
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  Uh, you know, I don't know if you heard that,
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  but it's just great.
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  And, uh, I think sometimes we're also busy getting work
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  done, you know, that as leaders, um, a lot of times we fail
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  to revisit processes and redesign and optimize them.
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  Um, you know, we kind of get stuck in this
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  is the way it's always been done.
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  And, you know, so we kind of stop asking the questions.
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  Um, I'm trained in Lean Office Six Sigma,
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  and while adopting like a formal methodology like that,
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  I think is great, and it is very
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  effective, it's not essential.
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  Um, I think that you can
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  apply process improvement methods without kind of
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  that more rigid formality.
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  Um, and I'll just mention a particular tool
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  that's been really effective for me.
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  Um, and it's called a cipo.
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  Um, it's actually an acronym
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  and it stands for supplier input, process Output and Custom.
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  Um, and it's a specific way to facilitate taking a team
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  through who supplies input to a process.
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  Is it members, providers, you know, internal departments,
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  um, what those inputs are, how they're processed,
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  what the outputs and out expected outcomes are,
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  and then who ultimately is the customer.
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  And from my experience, I've done so many of these,
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  these sessions, and you can do 'em in about a half a day,
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  and people are al always blown away by the things
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  that they didn't know, right?
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  Um, it gives managers visibility into things
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  that they're often unaware of, gives voice to people
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  that may not otherwise, you know, speak up
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  and have important things to contribute.
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  And it just helps root out where there are inefficiencies.
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  You know, and I'm just, I'm always astonished at
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  how organizations, you know, can work against themselves
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  by the sheer lack of the fact
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  that they don't have good cross-departmental communication
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  and process awareness.
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  So I know it's kind of a broad statement,
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  but I do think like just process improvement, um,
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  is really a key to any operational excellence, which again,
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  is at the bottom line of it all. Right?
• 9:12
  - Yeah. And that process improvement, as you sort
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  of pointed out there, requires that, that sort
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  of intentional communication that you detailed Mm-Hmm.
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  it requires that cross collaboration.
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  'cause as you mentioned, you know, people always are
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  surprised at what they don't know.
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  And it's, it is kind of astounding when you're not doing
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  that regular communication, all the stuff
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  that can be like floating under the radar
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  or the redundancies that can exist, right?
• 9:33
  - Absolutely. It is, it is amazing.
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  I've done so many of these sessions
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  and I always include managers and executives
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  and they, they'll walk away just, you know, amazed at
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  what they didn't realize.
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  Um, and they always come away with really great initiatives.
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  Um, and so they're very effective, I think.
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  - Mm-Hmm. it is some,
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  some really good tips there for, for improving processes.
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  And you have talked about technology as well,
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  and I wanna maybe zero in on that a little bit
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  because of course, innovation is sort of essential here
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  for this future of success of all healthcare organizations,
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  payers included, of course.
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  Yeah. Um, and how can you know, these organizations,
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  I guess, prioritize new technology investments
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  because there's just so much out there, you know,
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  and how can you really tap into the technology that's going
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  to support business needs
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  and those quality initiatives
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  that are gonna yield the results, uh, folks wanna see?
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  So what would you recommend here?
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  - So, yeah, so true.
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  And I think one of the first things I think is
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  that I think health plans should do
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  proof of concepts, right?
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  There's so much technology, as you said,
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  and vendors that are confident in their technology will
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  willingly, you know, do a proof of concept with you.
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  Um, and it's a great way to learn more about the technology,
• 10:44
  what its benefits are, and minimize risk.
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  Another thing, technique that I've used, you know,
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  as when I was a CIO,
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  we had many competing technology
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  projects, as you can imagine.
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  And so this may sound really simple,
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  but we would take all the projects
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  and we would plot them in a bubble chart,
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  like on an XY axis.
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  So we would get rough order of magnitude of complexity, risk
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  of cost, and of business value
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  or impact, and we would plot that.
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  And it's amazing how that visualization of all those,
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  those projects and initiatives, you know,
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  can give you a really quick look at where's the biggest
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  bang for the buck, right?
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  I think organizations should invest in business analysts.
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  They help bridge the gap, you know,
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  between it, um, and business.
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  And with technology playing such a more
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  and more critical role.
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  Um, I think that that's key.
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  Um, and then the last point I guess I'll make is
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  as both a process improvement consultant
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  and a technologist, you know, I think process always needs
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  to be revisited whenever ever you're undertaking a
• 11:49
  technology project, right?
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  I think there's nothing worse than implementing new
• 11:53
  technology around old business processes, right?
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  It's not a great way to optimize your investment.
• 11:59
  - Yeah. They, the two go hand in hand.
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  You can't, you can't do one without the other. Correct.
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  - You'd be surprised. ,
• 12:06
  - , I, I, you know, uh, a lot of will, can,
• 12:09
  can achieve a lot, I'm sure.
• 12:11
  Danielle, uh, thank you so much for,
• 12:13
  it's been such a treat speaking with you today.
• 12:15
  Is there anything else our, our listeners should know?
• 12:18
  - Yeah, I guess I, I would like
• 12:19
  to take this opportunity just
• 12:21
  to talk about very briefly two technologies that we,
• 12:23
  we do offer and, and, um,
• 12:25
  and we provide to our, you know, customers
• 12:27
  that are really beneficial in transformations.
• 12:30
  Um, one is a technology called Data Velocity.
• 12:33
  Uh, it uses AI machine learning, natural language processing
• 12:37
  to automate the intake of unstructured documents and data.
• 12:41
  Um, you know, with health plans, there's
• 12:42
  so much information coming in, scan documents, emails,
• 12:46
  faxes, phone calls, um,
• 12:47
  and these types of technologies can really help, um, improve
• 12:53
  the member or provider's journey, right?
• 12:54
  That's the first point of that journey.
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  And if you can, you know, process that quickly,
• 12:59
  categorize it, you know, get it pre-processed,
• 13:01
  you can really help improve customer service
• 13:03
  and that can improve things like your CAP scores in terms of
• 13:06
  how members will rate you.
• 13:08
  Um, the second technology, I'll try not
• 13:11
  to be too long-winded, uh,
• 13:13
  is insurance process automation suite.
• 13:15
  We call it IPAs.
• 13:16
  It's a technology that's been used in the traditional
• 13:19
  insurance industry for a really long time.
• 13:21
  Um, and we're starting to finally see
• 13:23
  some adoption in healthcare.
• 13:25
  Um, but it's basically a layer of technology that
• 13:28
  works with the systems.
• 13:29
  You have to orchestrate the movement
• 13:32
  of information in accordance with the business
• 13:35
  procedures and policies.
• 13:37
  Um, and a use case that I'll apply that
• 13:39
  to is appeals and grievances.
• 13:41
  So in appeals and grievances, you have all these documents
• 13:45
  and things coming in, and the caseworker has
• 13:47
  to get data from a lot of different systems.
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  And so the first thing a technology like this does is it can
• 13:54
  aggregate data from many places, right?
• 13:56
  So I can aggregate the member data
• 13:58
  and the claim information, benefit information,
• 14:00
  and all of that into what we call a single pane of glass.
• 14:04
  From there, you know, these types
• 14:06
  of platforms can apply processing rules.
• 14:09
  So to ensure things like timeliness,
• 14:11
  make sure this gets acknowledged
• 14:13
  or resolved on time, uh, routing rules,
• 14:15
  what's the next step in this process?
• 14:17
  Um, does it need to be submitted to an IRE?
• 14:19
  And by when, uh, and things like data validation rules
• 14:23
  and, you know, how does that all tie back
• 14:25
  to something like stars?
• 14:27
  Well, you know, ensuring meeting appeals, timeliness,
• 14:30
  which is a measure, um,
• 14:32
  utilizing things like historical data to predict, you know,
• 14:35
  if you should or should not submit an IRE
• 14:38
  to an independent us, submit a case
• 14:40
  to an independent review entity.
• 14:42
  Um, and then using all that great analysis data
• 14:45
  to provide operational insights, um, to root causes
• 14:48
  of member dissatisfaction, um, you know,
• 14:51
  around things like access to care
• 14:52
  and care coordination, uh, and customer service.
• 14:56
  Um, so I know I kind of put a lot out there,
• 14:58
  but again, I think there's a lot of great technologies
• 15:01
  that can help, but it definitely goes back
• 15:03
  to those three key points.
• 15:04
  People, process, technology, you know, that's the only way
• 15:06
  to drive any kind of transformation
• 15:09
  and operational excellence.
• 15:10
  And I think that that's what's key to Stars.
• 15:13
  - Yeah. A a and Daniel, thank you so much
• 15:14
  for, for laying all that out.
• 15:16
  I think we really, um, try to,
• 15:18
  to bring solutions oriented conversations to,
• 15:20
  to our audience, and I think you've really helped
• 15:22
  us achieve that goal today.
• 15:23
  So thank you so much for, for coming on the podcast.
• 15:26
  - Excellent. Thank you so much for
• 15:27
  having me. I really appreciate it.
• 15:29
  - Yeah, it's been a real pleasure.
• 15:31
  And I also want to thank of course our sponsor Inspire
• 15:33
  Innovations for helping us put this podcast together.
• 15:35
  You can tune to more podcasts
• 15:37
  and virtual events from Becker's Healthcare
• 15:39
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