Latest / Becker’s Payer Issues Podcast / Beyond Star Ratings: What High-Performing Medicare Advantage Plans Do Differently

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Beyond Star Ratings: What High-Performing Medicare Advantage Plans Do Differently · Becker’s Payer Issues Podcast

• 0:00
  - Hi, everyone. This is Madeline Sheets with Becker's
• 0:02
  - Healthcare. Thank you so much for tuning in
• 0:04
  - to the Becker's Healthcare podcast series. Today, we're
• 0:06
  - going to talk about Beyond Star ratings, what
• 0:09
  - high performing Medicare Advantage Plans do differently.
• 0:12
  - Our guests today are Rick Gordon and Nicole
• 0:15
  - Ziliak of Milliman MedInsight.
• 0:17
  - Rick Gordon is the director of government programs
• 0:20
  - at Milliman MedInsight,
• 0:22
  - where he leads strategy and growth for the
• 0:24
  - organization's government health care portfolio,
• 0:26
  - including Medicare Advantage, Medicaid, ACA Marketplace, and value
• 0:31
  - based solutions.
• 0:32
  - He works with health plans and provider organizations
• 0:34
  - to advance enterprise and analytics,
• 0:36
  - risk adjustment, quality improvement, and population health strategies.
• 0:40
  - Before joining Milliman Med Insight, Rick spent more
• 0:43
  - than two decades in health plan executive leadership,
• 0:46
  - building and operationalizing
• 0:48
  - government health care programs across Medicaid Advantage,
• 0:51
  - DS and P, CS and P, Medicaid, LTSS,
• 0:55
  - financial alignment demonstration,
• 0:57
  - and ACA marketplace products. His leadership experience spans
• 1:01
  - operations, product strategy,
• 1:03
  - STARS, risk adjustment,
• 1:05
  - regulatory
• 1:06
  - compliance, and value based care.
• 1:08
  - Rick is a recognized thought leader on government
• 1:11
  - health care transformation,
• 1:12
  - helping organizations
• 1:14
  - leverage analytics and technology to improve financial performance,
• 1:17
  - regulatory readiness, and clinical outcomes.
• 1:20
  - He frequently speaks on Medicare Advantage, Medicaid, risk
• 1:23
  - adjustment,
• 1:24
  - AI and health care, quality improvement, and the
• 1:27
  - evolving government healthcare landscape.
• 1:30
  - Nicole is director of clinical products at Milk
• 1:32
  - MedInsight,
• 1:33
  - the data and analytics division of Millimet.
• 1:36
  - She leads the development of solutions that integrate
• 1:38
  - clinical and claims data to support value based
• 1:40
  - care, quality measurement, and performance improvement,
• 1:44
  - turning fragmented data into a reliable,
• 1:46
  - actionable picture of care that helps plans and
• 1:49
  - providers close quality gaps, strengthen risk adjustment accuracy,
• 1:53
  - and meet evolving
• 1:54
  - reporting requirements.
• 1:56
  - Rick and Nicole, welcome to the podcast.
• 1:58
  - Thanks for having us. So excited to dive
• 2:01
  - in with you both. So, Rick, I'd actually
• 2:02
  - like to kick things off with you.
• 2:04
  - So stark ratings have taken center stage for
• 2:07
  - recalculation,
• 2:08
  - legal challenges, and proposed reforms in the 2027
• 2:12
  - MA rule, occurring alongside greater scrutiny of risk
• 2:15
  - adjustment and coding integrity.
• 2:17
  - So from your perspective, could you share how
• 2:19
  - that environment has changed what plan leaders can
• 2:22
  - no longer afford to manage as separate initiatives?
• 2:26
  - Yeah. Thanks, Maddie.
• 2:27
  - You know, I don't think plan leaders can
• 2:30
  - afford to manage quality
• 2:32
  - risk adjustment,
• 2:33
  - clinical operations,
• 2:34
  - provider engagement,
• 2:36
  - or, even compliance
• 2:38
  - as separate initiatives.
• 2:40
  - Over my career leading Medicare and Medicaid health
• 2:42
  - plans, you know, I've seen how those functions
• 2:44
  - or or operational teams often develop their own
• 2:47
  - data sources,
• 2:48
  - sometimes their own provider communications,
• 2:51
  - incentives, and definitions of success.
• 2:53
  - You know, and then, ultimately, they become siloed.
• 2:56
  - Right? But from the member and provider's perspective,
• 2:59
  - they're all part of the same care experience.
• 3:02
  - And so it's becoming clear
• 3:04
  - that CMS is evaluating them that way too.
• 3:07
  - If we take for a second, you know,
• 3:08
  - we consider a member with diabetes and congestive
• 3:11
  - heart failure. You know, the accurate risk adjustment
• 3:14
  - depends on those conditions being assessed, documented, and
• 3:17
  - supported
• 3:17
  - by the medical record. You know, the quality
• 3:19
  - performance depends on whether the member receives
• 3:22
  - the right
• 3:24
  - monitoring, medications, and the right follow-up.
• 3:26
  - Utilization and care management depend on whether the
• 3:29
  - plan can translate that information into,
• 3:31
  - you know, an effective inter
• 3:33
  - intervention.
• 3:34
  - And then, you know, the member experience depends
• 3:36
  - on whether all that feels coordinated rather than,
• 3:39
  - you know, a fragmented
• 3:40
  - experience.
• 3:41
  - So I think too, though, that the the
• 3:43
  - regulatory signals are also converging. You know, CMS
• 3:46
  - refocused the twenty twenty seven star ratings toward
• 3:49
  - clinical outcomes and patient experience,
• 3:52
  - but they also expanded RAD b oversight, and
• 3:54
  - they're requiring stronger evidence connecting diagnoses
• 3:58
  - to, you know, the actual encounters.
• 4:00
  - We know CMS is moving toward, you know,
• 4:03
  - auditing every eligible MA contract each payment year,
• 4:07
  - And we know that the unsupported diagnoses
• 4:10
  - are potentially subjected to, you know, extrapolated recovery.
• 4:13
  - So in saying all that, those are not
• 4:15
  - separate quality and coding developments. I think rather
• 4:19
  - together, they're signaling that payment, documented disease burden,
• 4:23
  - the care delivery, and the outcomes must all
• 4:26
  - tell the same consistent story. So plans should
• 4:29
  - be making a strategic shift from, you know,
• 4:32
  - optimizing these individual programs or initiatives
• 4:35
  - to building, you know, a more integrated performance
• 4:38
  - model. You know, the objective isn't to simply
• 4:41
  - find more codes or close more gaps.
• 4:44
  - It's really to identify the member's needs, support
• 4:46
  - the provider,
• 4:48
  - accurately document what occurred, improve the outcome, you
• 4:51
  - know, and then retain the evidence.
• 4:53
  - When those activities operate from the same data
• 4:56
  - and workflow,
• 4:57
  - you know, quality and risk adjustment become mutually
• 5:00
  - reinforcing
• 5:01
  - rather than competing priorities.
• 5:04
  - Thank you so much, Rick. And and, Nicole,
• 5:06
  - everything that he just described ultimately rests on
• 5:10
  - data, but that data is usually scattered across
• 5:12
  - clinical and claim systems that don't talk to
• 5:15
  - each other. So from your work integrating those
• 5:18
  - sources, what does it take to build a
• 5:20
  - picture of performance that plan leaders can trust
• 5:22
  - and act on?
• 5:23
  - That's a great question, Madeline, and it's a
• 5:25
  - question that I think analytics leaders across all
• 5:28
  - types of organizations are asking themselves.
• 5:31
  - I think the first thing to recognize is
• 5:33
  - that neither claims data nor clinical data tells
• 5:35
  - the whole story on its own.
• 5:37
  - Claims data is excellent for understanding utilization,
• 5:41
  - cost, and services delivered across the continuum,
• 5:44
  - but it often locks the clinical context of
• 5:46
  - why something happened or what the patient's condition
• 5:49
  - looked like at the point of care. And
• 5:51
  - that makes it really hard to interact with
• 5:54
  - clinical leaders.
• 5:55
  - Clinical data provides that context,
• 5:57
  - but it's typically fragmented across EHRs, labs, and
• 6:01
  - a lot of other systems.
• 6:02
  - The challenge is bringing those sources together in
• 6:04
  - a way that creates a single trustworthy view
• 6:07
  - of the patient and the population.
• 6:09
  - What it takes is not just connecting the
• 6:11
  - systems, but establishing a common framework so the
• 6:14
  - data can be normalized,
• 6:16
  - validated, and translated into consistent metrics.
• 6:19
  - Different systems capture
• 6:21
  - information differently,
• 6:23
  - and even small variations can create very different
• 6:26
  - performance results. So a significant part of the
• 6:29
  - work in data quality governance and it is
• 6:32
  - ensuring that when a plan leader looks at
• 6:34
  - a quality score or a utilization trend or
• 6:37
  - a risk indicator,
• 6:38
  - they understand exactly where that information came from
• 6:41
  - and they can trust it.
• 6:43
  - Once you've done that, something really powerful happens.
• 6:46
  - You're no longer looking backwards through separate reports
• 6:48
  - from claims and clinical.
• 6:50
  - You're looking to see performance in a much
• 6:52
  - more complete way. You can identify care gaps
• 6:55
  - earlier, understand the clinical drivers behind cost,
• 6:59
  - measure quality with greater precision, and focus interventions
• 7:02
  - on the members who will benefit most.
• 7:05
  - That's when the data moves from being just
• 7:06
  - a reporting asset to really being a decision
• 7:09
  - making asset.
• 7:10
  - Ultimately, that trust comes from the consistency,
• 7:13
  - transparency, and actionability of the data.
• 7:16
  - Leaders don't need more data. They're already drowning
• 7:19
  - in data.
• 7:20
  - They need confidence that the information they have
• 7:23
  - is accurate, current, and connected
• 7:25
  - well enough to guide meaningful decisions. And so
• 7:27
  - when you can achieve that, organizations can move
• 7:29
  - beyond asking what happens and start answering what
• 7:33
  - do we do next.
• 7:34
  - Thank you. Nicole, some great examples there. And,
• 7:37
  - Rick, when you look across the plans that
• 7:39
  - consistently improve year after year, what would you
• 7:43
  - say separates these?
• 7:45
  - Oh, yeah. I think it's clear that the
• 7:47
  - plans that are improving consistently
• 7:49
  - are are treating performance
• 7:52
  - more so as an operating discipline
• 7:54
  - and not just an annual campaign.
• 7:57
  - You know, they're they're not waiting for final
• 8:00
  - star ratings to come out or year end
• 8:02
  - results
• 8:03
  - or even, you know, the the final risk
• 8:05
  - score reconciliation to tell them what happened.
• 8:08
  - You know, those are all lagging indicators.
• 8:11
  - I think the the strongest plans establish an
• 8:14
  - early view of their performance. Right? They're they're
• 8:16
  - validating their performance continually,
• 8:19
  - and then they'll make the course corrections while
• 8:21
  - there's still time to influence the result. So
• 8:24
  - I generally see, you know, a number of
• 8:26
  - characteristics
• 8:27
  - in those organizations.
• 8:28
  - You know, they'll have a trusted enterprise data
• 8:31
  - foundation
• 8:32
  - rather than multiple teams producing different answers. So,
• 8:36
  - you know, think one source of truth. They'll
• 8:39
  - translate enterprise goals into their provider and member
• 8:43
  - level actions too. They'll prioritize
• 8:46
  - interventions
• 8:47
  - based on the potential impact
• 8:49
  - and the likelihood of closure rather than simply
• 8:52
  - producing larger work lists for their teams to
• 8:54
  - tackle.
• 8:55
  - I think they're building compliance into their workflow
• 8:59
  - with traceability from the identified opportunity through clinical
• 9:03
  - encounters
• 9:04
  - and then ultimately the supporting documentation.
• 9:07
  - And finally, I think they have an operating
• 9:09
  - cadence where leaders
• 9:11
  - are able to review barriers,
• 9:13
  - the outcomes, and accountability,
• 9:16
  - and not just activity volumes. Right? The best
• 9:18
  - plans
• 9:19
  - also seem to understand
• 9:21
  - the the populations that they're serving. You know,
• 9:24
  - I think a a strategy that may succeed
• 9:27
  - with a with a relatively healthy,
• 9:30
  - MA population
• 9:31
  - may not work for members who are dual
• 9:34
  - eligible or who have,
• 9:36
  - you know, social determinants of health barriers.
• 9:39
  - In my experience,
• 9:41
  - sustainable improvement occurs
• 9:43
  - when the plans can connect really three levels
• 9:46
  - of information.
• 9:47
  - The first being the enterprise view of performance,
• 9:50
  - the second being the provider's actionable
• 9:53
  - view of the patient, and then the third,
• 9:56
  - you know, the the member's actual experiencing,
• 9:59
  - accessing care through, you know, through their plan
• 10:01
  - or through their system.
• 10:02
  - So, you know, plans that can connect
• 10:05
  - those levels
• 10:06
  - seem to learn and adapt faster.
• 10:09
  - They can distinguish whether a gap reflects missing
• 10:12
  - data,
• 10:13
  - you know, whether it's an operational failure, a
• 10:16
  - provider barrier,
• 10:17
  - or, you know, a genuine unmet clinical need,
• 10:20
  - you know, and then and then make the
• 10:22
  - course correction from there.
• 10:24
  - And, Nicole, providers often describe quality gap closure
• 10:27
  - and risk adjustment
• 10:29
  - as separate overlapping requests that can create unnecessary
• 10:32
  - administrative burden. So from a data and workflow
• 10:35
  - standpoint,
• 10:36
  - how are the strongest plans bringing those efforts
• 10:39
  - together, and what role does unified clinical and
• 10:42
  - claims data kind of play in in making
• 10:43
  - that possible?
• 10:45
  - Great question. In in my experience,
• 10:48
  - the best performing plans have stopped treating quality
• 10:51
  - care closure gaps and, risk adjustment as separate
• 10:54
  - programs and sort of viewing them as two
• 10:56
  - outcomes of the same underlying objective,
• 10:59
  - which is building a complete and accurate picture
• 11:02
  - of each patient's health status.
• 11:05
  - Traditionally, providers receive one set of requests focused
• 11:08
  - on quality measures and then another focused on
• 11:11
  - documenting conditions for risk adjustment.
• 11:13
  - And for the providers, that often means multiple
• 11:16
  - outreach efforts, duplicate chart reviews, and additional administrative
• 11:19
  - work.
• 11:20
  - The organizations seeing the most success are redesigning
• 11:24
  - workflows
• 11:25
  - around the patient encounter
• 11:27
  - rather than around individual programs.
• 11:30
  - So they're asking themselves, how do we ensure
• 11:32
  - the right information is captured once and then
• 11:34
  - used for multiple purposes?
• 11:37
  - So that's the point where that unified clinical
• 11:39
  - and claims data becomes critical.
• 11:42
  - Claims data can tell you a patient had
• 11:44
  - a hospitalization,
• 11:45
  - they saw a specialist, or they received maybe
• 11:47
  - a particular service,
• 11:49
  - but the clinical data is providing that context
• 11:51
  - including the diagnosis,
• 11:53
  - the lab results, assessments, and the evidence of
• 11:55
  - the care delivered.
• 11:57
  - So when those data sources are brought together,
• 11:59
  - plans and providers can identify opportunities that simultaneously
• 12:03
  - impact both quality performance and risk accuracy.
• 12:06
  - To give you an example, a single patient
• 12:09
  - might visit might be used to close preventative
• 12:11
  - care gaps, address chronic disease management needs, and
• 12:14
  - also ensure appropriate documentation of conditions
• 12:17
  - that reflect the patient's true complexity
• 12:20
  - impacting those risk scores.
• 12:22
  - What we see among leading organizations we work
• 12:25
  - with is a shift from retrospective reporting
• 12:28
  - to proactive
• 12:29
  - action.
• 12:30
  - Instead of looking months later to see where
• 12:32
  - measures were missed
• 12:34
  - or which diagnosis weren't captured,
• 12:37
  - they're using integrated data to identify opportunities
• 12:40
  - before or during the point of care. That
• 12:43
  - allows them to present providers with a more
• 12:45
  - coordinated
• 12:46
  - and actionable view of what needs attention,
• 12:49
  - streamlining that reporting for providers and really minimizing
• 12:52
  - friction.
• 12:54
  - Ultimately,
• 12:55
  - that goal is to reduce friction for clinicians.
• 12:58
  - Providers don't want those separate workflows for quality
• 13:01
  - risk utilization,
• 13:02
  - value based care. They want that single prioritized
• 13:05
  - view of the patient, how they're working with
• 13:07
  - their patients. So when plans combine that for
• 13:10
  - them, the clinical and data the clinical and
• 13:12
  - claims data effectively,
• 13:14
  - they can align those efforts, reducing administrative burden,
• 13:17
  - improving member outcomes,
• 13:19
  - and creating a better experience for everybody who's
• 13:22
  - involved.
• 13:23
  - Yeah. And, again, another great example. Thank you,
• 13:25
  - Nicole.
• 13:26
  - So, Greg, quality risk adjustment and provider engagement
• 13:29
  - and an and analytics often report through different
• 13:33
  - leaders with different priorities.
• 13:35
  - So what does effective enterprise governance
• 13:38
  - look like in practice, and who ultimately has
• 13:40
  - to own performance across those functions?
• 13:43
  - Yeah. It's a it's a common struggle. Right?
• 13:46
  - I I think the most effective governance, you
• 13:48
  - know, begins with a with a simple principle.
• 13:51
  - You know, the the functional areas can retain
• 13:54
  - specialized responsibilities. Right? But the enterprise can't have
• 13:58
  - fragmented accountability.
• 14:00
  - You know, quality can own the the measure
• 14:03
  - strategy. Risk adjustment can own payment model expertise
• 14:07
  - and coding integrity.
• 14:08
  - Analytics can own methodology
• 14:10
  - and data controls, and and the network team
• 14:13
  - can own the the provider relationships.
• 14:16
  - But, ultimately, someone's gotta be accountable for how
• 14:18
  - those capabilities, you know, come together to produce
• 14:21
  - member outcomes and, you know, the sustainable
• 14:24
  - financial performance of the plan.
• 14:27
  - In practice, what I've seen,
• 14:29
  - to be, you know, one of the more
• 14:31
  - effective approaches is some sort of, you know,
• 14:34
  - executive steering committee or structure,
• 14:37
  - you know, that still has a single accountable
• 14:39
  - executive. Right? So, typically, the Medicare plan president,
• 14:42
  - the government program leader, or someone who are
• 14:45
  - similar business owner,
• 14:47
  - who's been empowered for that line of business.
• 14:49
  - You know, that that leader needs the authority
• 14:52
  - across all functions of the product.
• 14:54
  - The the committee itself can, you know, work
• 14:57
  - from one, you know, performance scorecard, you know,
• 15:00
  - one
• 15:02
  - defined set of definitions and, you know, a
• 15:04
  - clearly documented decision process.
• 15:07
  - And the committee should also have, you know,
• 15:09
  - operational work groups underneath it that can help
• 15:11
  - resolve
• 15:12
  - process issues quickly.
• 15:14
  - You know? But it's also important,
• 15:16
  - you know, for the governance model to maintain,
• 15:18
  - you know, a a meaningful independent
• 15:22
  - compliance function. Right? The business owns performance,
• 15:27
  - but compliance retains, you know, the authority and
• 15:30
  - the ability to challenge the methods,
• 15:32
  - you know, validate the different controls, escalate concerns,
• 15:36
  - you know, when needed without being subjected to,
• 15:40
  - you know, the the same revenue goals as
• 15:42
  - as other parts of the organization. Right? I
• 15:44
  - think that that distinction
• 15:46
  - is important, you know, as we see CMS
• 15:49
  - expand RAD b audits, you know, and and
• 15:51
  - remove diagnoses from unlinked chart review records,
• 15:55
  - you know, in this upcoming plan year for,
• 15:58
  - you know, in some cases.
• 16:00
  - You know, for organizations
• 16:02
  - that serve dual eligible members,
• 16:04
  - you know, governance across that Medicare
• 16:07
  - and Medicaid boundary, you know, that's that's also
• 16:10
  - an important distinction. CMS is already requiring greater
• 16:13
  - integration in areas like member materials and health
• 16:16
  - risk assessment.
• 16:17
  - In a, you know, in a dual plan,
• 16:19
  - the member doesn't experience Medicare and Medicaid as
• 16:22
  - two separate organizations.
• 16:24
  - So an integrated plan can't govern that way.
• 16:27
  - Ultimately, you know, at the end of the
• 16:29
  - day, the health plan CEO will remain accountable
• 16:32
  - for, you know, the the enterprise
• 16:34
  - performance in totality,
• 16:36
  - But day to day ownership has to live
• 16:38
  - with one empowered executive
• 16:40
  - whose, you know, incentives reflect quality risk, member
• 16:44
  - experience,
• 16:45
  - affordability,
• 16:46
  - compliance,
• 16:48
  - you know, altogether,
• 16:49
  - not one metric at the expense of the
• 16:52
  - others.
• 16:53
  - Yeah. And if you were advising a Medicare
• 16:55
  - Advantage executive team today, what would you tell
• 16:58
  - them to prioritize even over the next twelve
• 17:01
  - to twenty four months, and what leading indicators
• 17:04
  - would you want to know, that are on
• 17:06
  - track?
• 17:07
  - Yeah. So I'll I'll take the first stab
• 17:09
  - at the foundational elements of this before turning
• 17:12
  - it over to Rick for the the operational
• 17:14
  - perspective.
• 17:16
  - If I were advising a Medicare Advantage leadership
• 17:18
  - team today, I'd focus first on building a
• 17:21
  - unified quality and risk operating model,
• 17:24
  - with the data and workflow foundation to support
• 17:26
  - it. Too many organizations are still managing quality
• 17:30
  - risk adjustment member experience and utilization management of
• 17:33
  - separate programs,
• 17:34
  - as Rick highlighted,
• 17:36
  - with separate outreach,
• 17:37
  - analytics, and measures of success.
• 17:40
  - Their goal should really be a single member
• 17:42
  - and provider view that brings together claims, encounters,
• 17:45
  - clinical data, pharmacy information, supplemental data, member experience,
• 17:49
  - social risk information,
• 17:51
  - and then turns all of that information into
• 17:53
  - prioritized
• 17:54
  - actionable opportunities
• 17:56
  - that can be completed within the provider's existing
• 17:58
  - workflow.
• 17:59
  - And from a leading indicator perspective, I'd watch
• 18:02
  - whether actionable opportunities are reaching providers
• 18:05
  - before
• 18:05
  - or during the patient encounter,
• 18:08
  - how quickly those opportunities are being closed, and
• 18:10
  - whether the underlying data is trusted by both
• 18:13
  - the plan as well as the provider teams.
• 18:16
  - If those indicators are moving in the right
• 18:18
  - direction, then you're creating that foundation for sustainable
• 18:21
  - performance.
• 18:22
  - The goal is not better just a better
• 18:24
  - dashboard.
• 18:25
  - It's trying to convert that data into information
• 18:28
  - that creates a prioritized
• 18:30
  - action,
• 18:32
  - list that can be completed within the provider's
• 18:34
  - existing workflow.
• 18:36
  - Yeah. And and, Rick, any thoughts from you?
• 18:38
  - Yeah. I I agree, Nicole. You know, I
• 18:40
  - think once that foundation's in place, I'd I'd
• 18:43
  - probably also focus on a few additional priorities.
• 18:46
  - You know, I I think plans need to
• 18:48
  - make audit readiness a continuous process.
• 18:52
  - Monitoring
• 18:53
  - documentation
• 18:54
  - sufficiency
• 18:55
  - and counter linkage, their deletion pathways, provider patterns,
• 18:59
  - you know, and even their vendor performance throughout
• 19:01
  - the year
• 19:03
  - rather than trying to
• 19:04
  - reconstruct
• 19:05
  - or
• 19:06
  - duplicate those controls after receiving an audit notice
• 19:10
  - is critical. You know, CMS has signaled a
• 19:12
  - significant expansion
• 19:14
  - of its RAD b audit activity.
• 19:16
  - We know the level of scrutiny around, you
• 19:18
  - know, Medicare Advantage means plans need to treat
• 19:21
  - audit readiness as an ongoing operating discipline.
• 19:24
  - Next, I think it would be great if
• 19:26
  - we could redesign provider engagement around clinical relevance.
• 19:30
  - You know, every provider request that we have
• 19:32
  - should ideally combine
• 19:34
  - the member's suspected conditions,
• 19:37
  - any open quality opportunities,
• 19:40
  - you know, medication considerations,
• 19:42
  - and also the the relevant utilization history
• 19:45
  - into a, you know, clear, concise workflow.
• 19:48
  - I think we really need to stop asking
• 19:50
  - providers to to navigate
• 19:53
  - multiple provider
• 19:54
  - portals
• 19:55
  - and disconnected lists that, you know, reflect the
• 19:58
  - plan's internal organization
• 20:00
  - rather than the clinical encounter or the workflow
• 20:03
  - at the point of care.
• 20:04
  - And then finally, you know, I think plans
• 20:07
  - should really prepare for and anticipate
• 20:10
  - continuing
• 20:11
  - model and measure volatility. Right?
• 20:14
  - CMS, you know, retained the 2024
• 20:16
  - HCC model for 2027
• 20:19
  - rather than implementing
• 20:20
  - the newly proposed model, but it also finalized
• 20:24
  - the exclusion
• 20:25
  - of diagnoses from audio only encounters
• 20:28
  - and most
• 20:29
  - unlinked chart review records.
• 20:32
  - You know? And on the STARS front, CMS
• 20:34
  - removed 11 measures and refocused the program toward
• 20:37
  - outcomes and patient experience. So plans
• 20:40
  - need to develop scenario modeling. You know? They
• 20:43
  - need to develop adaptable workflows and and a
• 20:46
  - governance process
• 20:47
  - that's capable of responding to, you know, these
• 20:51
  - policy changes
• 20:52
  - without necessarily rebuilding their their operating model each
• 20:56
  - year.
• 20:57
  - And, you know, some of the leading indicators
• 20:59
  - I would watch out for,
• 21:01
  - documentation
• 21:02
  - support and, you know, coding deletion rates, I
• 21:05
  - I think, are gonna be critical.
• 21:07
  - Encounter acceptance,
• 21:09
  - reconciliation,
• 21:10
  - and submission timelines
• 21:12
  - are obviously very important.
• 21:14
  - The medication adherence curve
• 21:17
  - before the measurement year closes is is gonna
• 21:20
  - be critical going forward. The ability to forecast
• 21:23
  - accuracy across stars, RAF,
• 21:26
  - medical cost, and provider performance, as well
• 21:29
  - as vendor performance against the same compliance and
• 21:33
  - outcome standards applied internally, I I think are
• 21:35
  - all gonna be really, really important. You know,
• 21:38
  - as as Nicole mentioned, if those indicators
• 21:41
  - are improving together,
• 21:43
  - then I think, you know, the plan
• 21:44
  - can feel comfortable that it's probably creating a
• 21:47
  - real operating capability. But, you know, if the
• 21:50
  - RAF is rising while documentation integrity,
• 21:54
  - the quality outcomes, or the member experience are
• 21:57
  - deteriorating,
• 21:58
  - well, then I think that's a signal that,
• 21:59
  - you know, it's it's not sustainable performance, and
• 22:02
  - it's likely, you know, more so an emerging
• 22:05
  - enterprise risk.
• 22:07
  - Well, Rick and Nicole, thank you both so
• 22:09
  - much for your time and thoughtful insights today.
• 22:12
  - Such a great discussion.
• 22:13
  - We also want to thank our podcast sponsor,
• 22:16
  - Milliman MedInsight, and you can tune in to
• 22:18
  - more podcasts for Becker's HealthCare by visiting our
• 22:21
  - podcast page at beggershospitalreview.com.