The Provider’s Playbook for Medicare Advantage Plans

Medicare Advantage has been the subject of significant attention lately among provider organizations due to its distinctive demands that influence traditional practice operations norms. In this episode of Value-Based Care Insights, we sit down with Sarah Hartley, an expert in health information management, to discuss some of the hurdles with new Medicare Advantage contracts, along with the efforts needed to align providers and patients. Gain insights into the administrative challenges, diverse strategies for effective patient data management, and the essential cultural shift required to promote collaboration between provider organizations and payers.

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Transcript:

Daniel Marino:

Welcome to value-based care insights. I'm your host, Daniel Marino. There's been a lot of press recently, and really, over the last year about the challenges with Medicare advantage. Many health systems across the country are evaluating their role within Medicare advantage. And it's certainly has created. I think some, some challenges for these organizations as they think about how much they wanna position themselves within Medicare advantage, taking care of their patients within their community. And on top of that it's no secret. CMS is really pushing the industry towards Medicare advantage and really moving patients out of straight Medicare, and either to MA contracts or to ACOs. So it like I said it. It creates this challenge, but also does create some opportunity. And as well as there's been many organizations across the country who've been really challenged with Medicare advantage. Some of them have chosen not to participate Medicare advance contracts. There has been other provider organizations who been able to align well with certain payers. And have done reasonably well within the Medicare advantage space.

Well, I'm really excited today to have a guest who's been on the show before, Sarah Hartley. Sarah is the system director for a large health system here in Chicago. She leads the ambulatory risk, adjustment and clinical documentation, integrity, integrity work for the organization. She's been responsible for HIV departments. CDI programs both inpatient and outpatient and is really responsible for the alignment of practice operations with not only Medicare advantage contracts, but ACOs and other value based contracts as well. A wealth of knowledge and experience. Sarah, welcome to the program.

Sarah Hartley:

Thank you. I'm so glad to be here.

 

Daniel Marino:

Daniel Marino: So, Sarah, as I mentioned. You know it's no secret. Many organizations have really struggled with Medicare advantage. I think, from a from a couple of perspectives. Many of them have seen a lot of the administrative challenges associated with level of reimbursement for Medicare or Medicare advantage. There's challenges with getting recertifications. There are increased denials. There are administrative costs that that have been associated with managing the relationship. What are some of the challenges that that you've experienced or that you've seen, as you've worked through a lot of your MA contracts and your MA relationships with your payers?

 

Sarah Hartley:

I would say. Probably our biggest challenge is taking on that administrative burden and getting the position buy in in that, because there is a lot of administrative burden back from MA plans in terms of data, the amount of data that we receive, the requirements to meet all the measures, and so the challenge is, how do we make it? Easy enough for our physicians to address it with their patient, and meet the needs of our payers, as well.

 

Daniel Marino:

Yeah, I could see that. And you know the reimbursement. When you look at the economics, the reimbursement is at Medicare rates. Right? in some cases may even be below Medicare rates or associated with the Ma. Contracts, but the key to it is, as the performance of the plan improves, as the star ratings of the plans improve. Then there's associate. Then there's incentives that are associated with that right? So if you're if you're looking at a 4 and a half star rated plan. That incentive on top of the Medicare reimbursement is higher than it than a 3 and a half. But it does not take the place, I think, of the administrative services right that are required. Are you seeing when you talk to some of your colleagues, Are you seeing a an increase in a lot of, say, denials related to some of these preserts and other activities that you normally wouldn't get if you were in straight Medicare?

 

Sarah Hartley:

Yes, we see a lot of denials and research, the increased scrutiny. With our DME providers increased scrutiny with the annual wellness visits. There are quite a bit of denials coming through that we just don't know how to manage yet, especially in the new space.

 

Daniel Marino:

Well, a a absolutely, absolutely. And I think that's what a lot of folks are looking at. The other area that you touched on a little bit. It's the performance outcomes. So the other challenge that we have with Medicare advantage is not only are we faced with potentially higher denials and reduced reimbursement. But there's also performance outcomes that we have to hit as an organization. How have you been able to overcome that challenge?

 

Sarah Hartley:

I think the key is to have a holistic approach. We have to get out of working in silos and healthcare. The the goal is to keep our patients out of the hospital, and we have to work with our hospital providers and our outpatient providers to look at the patient as a whole and treat them as a whole. And so getting that data from our payers can really help us manage that. So getting the subject matter Experts at the table that can speak to each piece of that movement for the patient through the system.

 

Daniel Marino:

Has getting the data from the payers, you know. I know you have your own data, right? And you're looking at your billing data. You're looking at your quality data. I'm sure you know, you're fairly. You're pretty sophisticated. So you're looking at a lot of the reports to identify how you can kind of close the gaps and so forth. But the data from the payer is really important. Have you been able to create that alignment around sharing of that data with your payers?

 

Sarah Hartley:

Not yet. We are building a platform to do so. The challenge is that our internal data just looks at our claim. You know, a patient can go anywhere, and so when you look at them as a whole patient, their raft score their quality measures. Under that contract they can go anywhere, and the patient needs to be managed appropriately. So as we align, and we can see the data align. If we get it into one platform, then we can see the pictures, the pay. I'm sorry the patient whole story, regardless of where they go. So ingesting that data is the path that we're on right now to paint that picture of the whole story.

 

Daniel Marino:

Yeah. So it's really the claims data, right? Cause. As you said, patients go anywhere and you have your billing data. So you know what's occurring within your organization, but you don't necessarily know what if they you know you're in Chicago, so you may have a lot of folks that go down to Florida, right the snowbirds or the Arizona.

 

Sarah Hartley:

Correct.

 

Daniel Marino:

If you're responsible for them, you need to get that claim state and really begin to understand what's occurring as they do get care elsewhere. How about the vastness of the data? I mean, I one of the one of my clients I was talking to. We were helping with some modeling of a Medicare advantage contract and the amount of data that they have both internally in the organization. And then they did get sample data from the payer. Pulling that together was enormous is the vastness of the data. Typically an issue. It's a major issue E, especially if you think about all of the plans that you contract with. Everybody has a different way of looking at the data, they have different terms for their data. They have different processes, different platforms.

 

Sarah Hartley:

And then, when you get into managing all of the patients or all of the beneficiaries in those plans. It can be enormous and it's overwhelming. So the biggest question, the most important question to me is, what are we going to do with it? Is it actionable data?

 

Daniel Marino:

Yeah, I could. I could see that. And you know as well you want to manage the patients the same way across the entire practice. There's certain requirements from different plans, you know, some measures and capturing of some data within the care model is important to this plan, and there may be some other elements that we have to capture when for other plans. How are you managing across that with the physicians? Because I would think it would be either one really confusing, or you don't want your physicians to cherry pick right? Only do some patients and some on another. How do you manage through that.

 

 

Sarah Hartley:

Those are big discussions that we're actually having right now. Are we payer agnostic? Or do we drive based on the plan right? And so we're looking at. How do we help our providers in epic by highlighting the patient with the plan attached. I don't know that they're going to know what that means in the intricacies to the contract with the plan, but it will help the administrative staff at least.

 

Daniel Marino:

Yeah.

 

Sarah Hartley:

We really look at Payer agnostic as the approach right now and then manage the intricacies on the back end for our our providers.

 

Daniel Marino:

I absolutely think that's the way to go, because at the end of the day, and this is the conversation that I often have at the end of the day, we're entering into all of these contracts with payers, whether the fee for service or fee for value. But if you truly want to make a change. You have to manage the population. It's population health.

 

 

Sarah Hartley:

That's right.

 

Daniel Marino:

Yeah. And in some cases it's really how you form files function. Right? So as you start to think about all the different indicators it's almost like you. Will you have to do all this on on everything right, or at least begin to negotiate? What are the primary set of data elements that we need to capture or outcomes, we need to drive to and so forth and incorporate those in all of your contracts.

 

Sarah Hartley:

Correct, and I think the that's an important piece to think about. To who do you have at the table as you negotiate the contract. You need to have the subject matter experts at the table as well.

 

Daniel Marino:

Yeah, do you incorporate, like your physicians, or lead physicians in those conversations.

 

Sarah Hartley:

We do have physician, senior leadership that has conversations with our contracting department. I've had conversations. Our clinically integrated network is very aligned with our contracting department as well. So that we know very well kind of what our contracts are, and how we move forward.

 

Daniel Marino:

Well, it sounds like from the work that you've been doing. You really have to take a proactive approach on working through this with the payers, and I think this is in some cases what makes it difficult for some of some of the providers, you know in in my mind, and I'll let you respond to this. I think it comes down to 4 things, one understanding, currently where you are and where you need to go with your Medicare advantage contract. But there's a couple of other key pieces that, as you were talking sort of resonating with me, I think one is making sure you focus on the data to drive the change. I think the other is understanding the knowledge, right doing that, continuing education with your providers. But the last one is probably the culture. because it is it is a changing culture as you're moving from not just fee for service to fee for value, but straight Medicare to Medicare advantage. Thoughts on those.

 

Sarah Hartley:

It is a massive culture shift for the entire healthcare industry, and we have to help our providers come along with that. It is that, you know, Medicare says by 2030 they want all patients on a Medicare advantage plan. So this is not going away. And as we see these big health systems come together your challenge with merging the cultures of the multiple health systems and then changing the culture of the way that our providers have practiced, encoded, and build for their the entirety of their career. And so it's a huge shift for our providers. It's a huge shift for our patients and the staff that are part of the work.

 

Daniel Marino:

If you're just tuning in. I am Daniel Marino, and you're listening to value these care insights. I'm here talking to Sarah Hartley, and we're discussing how providers can guide success through a Medicare advantage contract. So building off of that, Sarah. One question has come to mind as you're going through this, you know, we're talking about what the what the providers need to do. What do you feel like the payers need to do to reposition themselves to improve that relationship with the providers.

 

Sarah Hartley:

They have to support us. I think there is. And when I say support, I mean, we need education. There is not a lot of subject matter experts out there in the ambulatory value based care, space, right? We started in the inpatient world. So how do how do our payers, who are the experts in this help the providers get to the next level. They have all kinds of educational resources for us, but they're recorded webinars and things like that. So when you have a dedicated team from your payer, the support from them, the meetings, understanding the metrics, asking, you know how they can get us the data. Is there an epic pay or platform, or some other electronic health record that they can provide us the data to interface for our providers. But really, the education, understanding the data and any interfaces that we can get to see the patient picture as a whole is really important, and then partnering with the person whose job it is on the provider side to do care management or care coordination, or HCCs with the partner on the payer side. So that you are speaking the same language.

 

Daniel Marino:

Well, and the partnering the collaboration is, is such an important factor on driving this success. If you think about it we all have the same goal. right? We wanna provide the highest level of quality to our patients at the lowest possible cost. Right? It sort of aligns around the triple, the triple. A. So if that's the goal, what I feel like is a breakdown between the payer and the provider. Each of those entities, if you will have a different approach to get there right. And you know again, if you're not aligned and you're not taking the same road, if you're not collaborating on the best path to achieve that goal. Then you're gonna continue to have challenges. And I think that's what you're pointing out. Perfect example is care management that's being provided in the provider community and case management that's being provided by the payer.

 

Sarah Hartley:

Correct, correct. And we are challenged with that because there's diagnoses that come out of their that care management by the payer that are not validated or ever seen on the provider side. So the challenge then becomes with matching up the data, making sure that it's accurate you again, not speaking the same language. We're not even reading from the same playbook at that point. So really making sure that we have the right data and the same data on our patients is going to be really important.

 

Daniel Marino:

Why don't you think payers maybe collaborate more or as much as they should with the providers? Do you feel like maybe the financial incentives are not aligned. Or maybe they're just struggling with the same thing. The providers are struggling with, such as the vastness of the data and understanding where to start any thoughts.

 

Sarah Hartley:

So I think it's twofold. I think one. You're right. The vastness of the data. There's just so much data. But from my experience with all of our Payer partners. They want to work with us. They are eager to work with us. The challenge on our end is that we are so overwhelmed with the amount of data and the amount of asks coming to us on the administrative side that it's challenge a challenge for us to do so. They are very eager, because I think they have incentives on their end as well. Right? So it benefits them, but I think it takes the health system, the provider wanting to align and understanding the importance of that. I have asked that my, that all of the risk adjustment. HCC. Work be broken out of the overall quality meeting, because I'll end up getting 5 min of my meeting. So really, having focus time to deep, dive deep into the data with your payer partner is important, and you have to look at it from your perspective. And then, as a whole picture.

 

Daniel Marino:

That's such a great point, right? So you're really aligning them where you want to go. And you know, the payer being that they have a level of information and data that that you as a provider don't have. But you have a level of information. Certainly the clinical data that the payer doesn't have, I think, to be able to come together to really deliver a more comprehensive view for that patient through that level of collaboration. That's what's gonna drive the results.

 

Sarah Hartley:

Absolutely right, and that is what is going to keep our patients healthy and out of the hospital.

 

Daniel Marino:

Yeah. So when you think about recommendations, when you think about how organizations maybe can take that misaligned relationship if you will and steer it the right direction, is there? Is there some key recommendations that that you'd like to put forth, maybe to some of the folks on the call that are in the payer community, or even in the provider space.

 

Sarah Hartley:

First I would say, align your subject matter, experts. You have to have the right knowledge to move the needle and have the conversation, and then make sure you have the the necessary data, and for the provider side it, it's back to basics. Why is this important? How does it impact them. What is it going to do for their patients and really make it important for them, and make sure that they understand it? That's going to help start to drive the change, and when you find your champion they can certainly help. Pro. Excuse me, partner with the providers or the payers. I'm sorry as well to help us kind of move that needle forward. But I would say foundational work and laying the groundwork, making sure the knowledge is there the subject matter? Experts are there. We have the culture, the necessary data, and the tool alignment to move forward.

 

Daniel Marino:

So I would think that you would have your regular operational meetings, where you would think about working through with the payer on how to align pairs probably there, and have that level of rep representation. but in some cases it probably only takes you so far right. In other words, you work them out of that? It's like, okay, this, that's a really good meeting. But then, where do you take it? How much of a higher level governance type of a structure is important. So you mentioned senior leaders of the help of the of the of the health system. But I also feel like, it's important to have senior leadership of the payers come together as well, too, because if you're gonna really drive the culture change, it needs to come from the top.

 

Sarah Hartley:

Absolutely. And what is our goal, you know? Set a 3 year plan, goal or a year plan goal at the higher level, at the senior leadership level, and we're aligned with the payer and the provider on our goals going forward? Are we gonna meet 5 stars this year? Is it going to be 4 and a half? You know? What are our goals, and then meet regularly whether it's quarterly, you know, Every other month with the senior leadership, but may align from top to bottom, is really gonna help move that needle forward as well.

 

Daniel Marino:

Yeah. And I'll tell you many times this was a lot of the the clients that we have. That higher level governance is really missing. I really feel like that's a that that could be a big opportunity for change. And I think a lot of times organizations, both the payers and the providers. They're still negotiating from the framework of fee for service, not the framework for fee for value, and certainly not collaborating as much as they should.

 

Sarah Hartley:

Right. I I think it's important for the Pro. The payers to really understand the challenges of the provider, you know, because what we're challenged with is, the more we put on our providers, the more they dig their heels in. They can't possibly do another annual wellness visit their schedule is full well, that's on us to figure out how to open the doors for them. But we have to have alignment across the system, because everywhere kind of trickles down.

 

Daniel Marino:

Yeah.

 

Sarah Hartley:

So Yup even. And when I say executive senior leadership, I mean inpatient, outpatient, acute care, ambulatory. It is a full circle, holistic picture of the patient, and that's how we should be strategizing as well.

 

Daniel Marino:

Do you think we given your experiences with working with the payers? You you're very proactive, and I give you a lot of credit for that. I think that's what's driven a lot of the change. Maybe some number of organizations don't have an individual like you who's really pushing that I think that's a big credit to you. Do you think it would be important to create almost like a third party to come in? Maybe somebody who's agnostic and manage managing the data, or somebody who's agnostic in managing care management, right between the provider and and the payer. Do you think that's a role that could potentially work. Or do you feel like, maybe, hey, we have the resources between the payer and the provider. We just need to agree to work together and collaborate more.

 

Sarah Hartley:

I would say. It depends on how large the health system is. From my perspective, a 9 hospital health system. We are absolutely too large to manage that all of that data internally. So we do, partner, with a vendor that helps bring all of that data together. So not just our claims, data, our affiliate claims, data, and our internal EHR data as well as our affiliate EHR data. So we are able to see the picture of the patient. All of our patients that are on our rosters. From our affiliates and our employee providers from the claim, perspective and the medical record perspective. So we're doing what our longitudinal record cannot do in a separate tool which is going to give us that full picture of the patient.

 

Daniel Marino:

Yeah. Well, and I think, having a third party in there that can help one bring it all together. They have the expertise, and you're not going to recreate that in internally, but they also they provide, I would think, an unbiased view of both your health system or a health system, and the payer which would help you move a little bit quicker. So I can see a lot of value with that.

 

Sarah Hartley:

Yeah, lots of value.

 

Daniel Marino:

For any of our listeners who, as I mentioned, come from the provider space or come from the payer space any pieces of advice? If you were to give a you know a quick 30 s recommendation to how they can work better towards getting themselves more aligned around the Medicare advantage contracts or their performance of their patients. Any thoughts come to mind, where, where should they start.

 

Sarah Hartley:

Start with understanding where you are. where you are, in your contract, where you're going with the contracts, aligning your quality measures. Looking at your MLR, your star ratings, Making sure that you have the right data and the right people in line to make those decisions, to start driving that culture change.

 

Daniel Marino:

Yeah. And I think what's clear coming out of our conversation today is you have to be proactive. You can't sit back and let the payers drive it. You? Yeah. As a health system. You really do have to drive that and make sure that you're putting forth that culture of collaboration. I think that's key.

 

Sarah Hartley:

At the end of the day we are in control of the data.

 

Daniel Marino:

Yeah. Great point. Great point. Well, Sarah, I want to thank you for coming on today. This is this is great, and I know it's a it's an important topic that many of our listeners can relate to. And I think, as we continue to see a shift into value based care. We have to do a better job of creating success around Medicare advantage. So I commend you and your team for the work that you're doing thanks again for coming on today.

 

Sarah Hartley:

Thanks for having me.

 

Daniel Marino:

And I want to thank everyone for listening and for you all tuning into value based care insights until the next insight. I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners