Latest / Becker’s Payer Issues Podcast / Improving Medicare Advantage Star Ratings Through Care Management and Data Sharing with Dr. Sanjiv Shah

Transcript

Improving Medicare Advantage Star Ratings Through Care Management and Data Sharing with Dr. Sanjiv Shah · Becker’s Payer Issues Podcast

• 0:02
  - GLP ones, Medicare Advantage Headwinds, a Medicaid landscape
• 0:06
  - that looks different
• 0:07
  - every quarter.
• 0:09
  - Their leadership right now means making durable decisions
• 0:11
  - in an environment that keeps moving, and the
• 0:13
  - organizations pulling ahead are the ones that stopped
• 0:16
  - waiting for stability
• 0:18
  - before acting. Becker's fifth annual fall payer issues
• 0:21
  - roundtable convenes more than 500
• 0:24
  - executive level attendees
• 0:25
  - and 70 plus speakers November second and third
• 0:28
  - at the Swiss Hotel Chicago.
• 0:30
  - Two days of senior level dialogue on affordability,
• 0:33
  - benefit design, value based care, and the strategies
• 0:36
  - shaping how care gets financed
• 0:39
  - and delivered. Featuring a celebrity keynote from pro
• 0:40
  - football hall of famer, Emmitt Smith. The
• 0:41
  - celebrity keynote from pro football hall of famer,
• 0:44
  - Emmitt Smith. Agenda and registration at beckerspayer.com.
• 0:47
  - Click events in the upper right.
• 0:51
  - Hi, everyone. This is Elizabeth Caslow with the
• 0:53
  - Becker's Payer Issues podcast.
• 0:55
  - I'm thrilled today to be joined by doctor
• 0:57
  - Sanjeev Shah, chief medical officer at MetroPlus Health.
• 1:01
  - Sanjeev, thank you so much for taking the
• 1:03
  - time to chat with us today.
• 1:05
  - My pleasure, Elizabeth. Good to join you. We're
• 1:07
  - so excited to have you. And before we
• 1:09
  - jump in, I would love to hear a
• 1:10
  - little bit more about you and your career
• 1:13
  - background and your current role at MetroPlus Health.
• 1:16
  - Yeah. I've been, in managed care since 2004,
• 1:20
  - but the journey was unexpected. I was a
• 1:22
  - internal medicine infectious disease doctor practicing in the
• 1:25
  - Bronx,
• 1:26
  - New York, and pursuing
• 1:28
  - my master of public health at the Mailman
• 1:30
  - School of,
• 1:31
  - health in... At Columbia University. And
• 1:34
  - a request came by that they were looking
• 1:36
  - for a part time medical director
• 1:38
  - at a New York City based plan called
• 1:40
  - MetroPlus,
• 1:42
  - Health.
• 1:43
  - And
• 1:44
  - in specializing in HIV care, we have one
• 1:47
  - of the three HIV SNPs, in New York
• 1:49
  - state,
• 1:50
  - and they're looking for a medical director. So
• 1:52
  - with my background in infectious disease, I was
• 1:55
  - interested in that role as I was pursuing
• 1:57
  - my Miles per hour. It was a lot
• 1:58
  - to tackle, do both things.
• 2:01
  - So this part time opportunity came along, and
• 2:03
  - I've been in managed care ever since.
• 2:05
  - That's great to hear, and welcome to the
• 2:07
  - payer podcast.
• 2:09
  - So MetroPlus Health just got its second consecutive
• 2:12
  - four star Medicare Advantage rating from CMS.
• 2:15
  - So what has your team specifically focused on
• 2:18
  - that's driven that rating? And would you mind
• 2:19
  - giving us an example of what that looks
• 2:21
  - like in practice?
• 2:23
  - Sure. We are,
• 2:25
  - almost
• 2:26
  - 95,
• 2:27
  - 97%,
• 2:29
  - in our Medicare Advantage phase jewels.
• 2:32
  - So we're very much guided by the CMS
• 2:34
  - model of care, and we
• 2:36
  - very much adhere to it. So the central
• 2:38
  - foundational strength is care management
• 2:41
  - And,
• 2:43
  - with high risk members, medium risk, low risk,
• 2:45
  - we provide care management
• 2:47
  - depending on that risk profile
• 2:49
  - as needed.
• 2:51
  - And so that is the first and most
• 2:54
  - important
• 2:55
  - foundational strength. And on top of that, we
• 2:57
  - build
• 2:58
  - a very sound quality management framework. I oversee
• 3:01
  - quality management
• 3:02
  - and care management,
• 3:03
  - at, Metro Plus.
• 3:05
  - And then
• 3:06
  - couple that with, as you can imagine, with
• 3:08
  - this population that's mostly duals,
• 3:12
  - the importance of pharmacy
• 3:14
  - and,
• 3:16
  - a strong partnership
• 3:18
  - with providers.
• 3:19
  - MetroPlus is a wholly owned subsidiary of New
• 3:22
  - York City Health And Hospitals, so we work
• 3:24
  - closely
• 3:25
  - with large health systems like,
• 3:27
  - H and H, but also
• 3:28
  - independent providers in the community,
• 3:30
  - FQHCs,
• 3:31
  - but people who are just
• 3:33
  - community providers. And so we're always balancing
• 3:36
  - that triad of plan
• 3:39
  - member, and provider with a member as the
• 3:41
  - sort of central focus or attention through the
• 3:44
  - model of care.
• 3:45
  - And what gaps in care have you historically
• 3:48
  - observed, and how have you addressed those through
• 3:50
  - some of the things you just talked about?
• 3:53
  - Well, I think you can...
• 3:55
  - A a good example would be,
• 3:58
  - when when a MetroPlus
• 4:00
  - Medicare member is admitted to the hospital.
• 4:02
  - If you're a large health system and you're
• 4:05
  - on EPIC,
• 4:06
  - many a time through Epic Care Bureau, you're
• 4:08
  - very aware of that admission.
• 4:10
  - You know it's occurred through,
• 4:12
  - your Epic InBasket and you,
• 4:14
  - learn about the admission. You can potentially contribute
• 4:17
  - to that admission by getting in touch with
• 4:18
  - the inpatient team. But if you're a community
• 4:20
  - based provider not on Epic
• 4:22
  - and not connected that way,
• 4:24
  - you may be oblivious to that admission. You
• 4:27
  - may not know it's occurred in our role
• 4:29
  - as the managed care plan and with Medicare
• 4:32
  - Advantage is
• 4:33
  - once we're notified,
• 4:35
  - the first thing we do is outreach to
• 4:36
  - the primary care provider and let them know
• 4:38
  - that admission has occurred.
• 4:40
  - We then track the admission throughout its course.
• 4:43
  - And around the discharge, we,
• 4:45
  - supplement that information by providing the discharge summary
• 4:48
  - to that PCP. Whether they're in the community
• 4:50
  - or health system,
• 4:52
  - our goal is to get that primary care
• 4:54
  - provider the discharge summary with all the follow-up,
• 4:57
  - medication changes that may or may not have
• 4:59
  - occurred,
• 5:00
  - and the follow-up that's needed.
• 5:01
  - And then connecting that
• 5:03
  - member back to the provider in a timely
• 5:06
  - fashion, our goal is seven days, but certainly
• 5:08
  - within thirty days, and then ensuring
• 5:11
  - through that process
• 5:12
  - avoiding
• 5:13
  - readmissions.
• 5:14
  - The all plan cause readmission measure is a
• 5:17
  - triple weighted measure.
• 5:19
  - The only way to ensure that those individuals
• 5:22
  - get the care they need is by creating
• 5:24
  - that very solid bridge between the hospital and
• 5:27
  - the community,
• 5:29
  - through the work of our care managers. And
• 5:31
  - the providers are very grateful for that information
• 5:33
  - because,
• 5:34
  - again,
• 5:35
  - Elizabeth, many a time, they're oblivious to that
• 5:38
  - notion that their patient has just been admitted.
• 5:41
  - So those are gaps in care that we
• 5:43
  - try to fill,
• 5:44
  - through this,
• 5:46
  - care management process that I've just outlined.
• 5:49
  - And what do you think some of the
• 5:50
  - main challenges will be,
• 5:52
  - as you go into star ratings next year?
• 5:54
  - I know it's kinda funny to talk about
• 5:55
  - that now. But thinking ahead, how are you
• 5:58
  - preparing?
• 5:59
  - Yeah. You're spot on. You can't, rest on
• 6:02
  - your laurels. You've got to constantly be thinking
• 6:04
  - about the next challenge.
• 6:06
  - So I I know that there's a lot
• 6:09
  - of focus now as... And we have that
• 6:10
  - focus in our quality management department, in our
• 6:13
  - analytics
• 6:14
  - unit
• 6:15
  - on
• 6:16
  - electronic clinical data exchange
• 6:19
  - and digital quality reporting. It's,
• 6:22
  - it's just taking
• 6:23
  - a huge leap forward.
• 6:25
  - The re... The recent NCQA conference emphasized the
• 6:28
  - importance of that, and we need to make
• 6:30
  - sure
• 6:31
  - that large health systems are obviously potentially very
• 6:34
  - well equipped to meet those challenges of digital
• 6:37
  - quality measure reporting. But is the FQHC in
• 6:40
  - the community equipped? Our individual providers who take
• 6:43
  - very good care of our Medicare members, are
• 6:46
  - they equipped? And so one of the things
• 6:48
  - we're...
• 6:49
  - We need to do as a plan is
• 6:50
  - to outreach all the providers and get a
• 6:53
  - sense of their ability
• 6:54
  - and capacity,
• 6:57
  - to exchange clinical information,
• 6:59
  - how well is it, being accessed so that
• 7:02
  - we don't have a care
• 7:05
  - data gap, developing as a result of,
• 7:08
  - of these
• 7:09
  - clinical digital
• 7:11
  - quality reporting requirements.
• 7:14
  - I know this year around the SAR rating
• 7:16
  - season, I chatted with a few different plans.
• 7:18
  - You know, we're talking about the resources they
• 7:20
  - have, but they wanna boost their ratings
• 7:23
  - despite limited resources.
• 7:25
  - So what advice do you have? Like, what
• 7:27
  - is the main clinical lever that they should
• 7:29
  - be targeting for next year? Even if they're
• 7:31
  - not necessarily in the SNP space, what should
• 7:34
  - they be thinking about?
• 7:36
  - Yeah. I think,
• 7:37
  - for me,
• 7:38
  - the profound importance of information exchange as
• 7:43
  - the oxygen
• 7:44
  - for
• 7:45
  - good patient care in this current environment.
• 7:47
  - And
• 7:48
  - how do you leverage that information efficiently,
• 7:51
  - accurately is going to be essential, and we
• 7:54
  - play a role in it. The,
• 7:57
  - electronic health records, sphere plays a role in
• 7:59
  - it, and the providers need to... If they
• 8:01
  - can't do it themselves, assign someone that we
• 8:03
  - can work with,
• 8:05
  - to... So they... They're they're adequately informed in
• 8:08
  - that space. I'll give you a a very
• 8:11
  - concrete example. You're probably aware, Elizabeth, about the
• 8:14
  - advent of continuous glucose monitors,
• 8:16
  - which have been a tremendous boon to our
• 8:19
  - patients living with diabetes.
• 8:21
  - But,
• 8:22
  - through that process, there's a way to calculate
• 8:25
  - their glycemic control, their glucose control. It's called
• 8:28
  - the GMI that the instrument calculates.
• 8:31
  - That's a proxy for the hemoglobin a one
• 8:33
  - c that
• 8:35
  - for years and years, the providers have used
• 8:37
  - to tell them how their patients with diabetes
• 8:41
  - are faring in terms of their sugar control.
• 8:43
  - Well, that GMI reading is maybe obvious to
• 8:46
  - the patient, but it's not obvious to the
• 8:48
  - clinician that we... If they can access it
• 8:50
  - and send it to us, that's their proxy
• 8:53
  - for a one c reading. So that sort
• 8:55
  - of information that we need to disseminate and
• 8:58
  - gather and transmit
• 8:59
  - between each other is going to be critical,
• 9:02
  - over the next few years.
• 9:05
  - Yeah. And I'm thinking immediately going into 2027
• 9:08
  - with the interoperability,
• 9:09
  - you know, requirements that are coming into play.
• 9:12
  - It's gonna be really interesting to see how
• 9:13
  - that all flows so soon.
• 9:15
  - Sanjeev, do you have any final thoughts and
• 9:17
  - advice
• 9:18
  - for other industry leaders?
• 9:21
  - I... Much of what I wanted to convey
• 9:23
  - have outlined,
• 9:25
  - but, again, I think the other central piece
• 9:27
  - of this is I know there's a fair
• 9:29
  - amount of competition
• 9:30
  - around star ratings,
• 9:32
  - but there's a tremendous opportunity to collaborate. A
• 9:35
  - rising tide truly lifts all boats here.
• 9:38
  - And,
• 9:39
  - I see patients one day a week. I'm
• 9:41
  - oblivious to which insurance plan they have. What
• 9:44
  - I want is
• 9:45
  - access to timely information so I can take
• 9:47
  - the best care for my patients.
• 9:49
  - And I think if we all collaborate in
• 9:52
  - that space and learn best practices with each
• 9:54
  - other and share them,
• 9:56
  - we will have a tremendous,
• 9:58
  - outcomes and and truly, I think, better patient
• 10:02
  - care and and more efficient, patient care with
• 10:05
  - the primary care as the central focus for
• 10:07
  - all of that care.
• 10:09
  - Well, Sanjeev, thank you so much for taking
• 10:11
  - the time to chat with us today.
• 10:13
  - My pleasure, Elizabeth. Cheers.
• 10:15
  - Cheers to you too. And to our listeners,
• 10:18
  - if you'd like to listen to more podcasts
• 10:19
  - from Becker's Health Care, you can visit beckershospitalreview.com.
• 10:23
  - Thank you.