A few weeks ago, Chris Skowronek, VP of Corporate Strategy & Partnerships, and Alycia Sepe, VP of Business Development, Payer & State Government Markets were guests on an America’s Health Insurance Plans (AHIP) webinar to highlight changes to 2023 Star Ratings and how Real-Time Care Intelligence™ connects the dots between payers and providers.

The following excerpt is a summary of Chris and Alycia’s presentation. You can watch the full webinar recording here.

The shift to value-based care is having a seismic impact for health plans in terms of how they reimburse for care and support their members. The Centers for Medicare & Medicaid Services (CMS) continue to drive health plans towards value and quality-based arrangements, leaving health plans with the responsibility to shift towards these models.

In addition to the demands of CMS, there are several external industry-wide and economic factors that are driving health plans towards value-based reimbursement models, including:

• The continuous rise of healthcare costs: About $12,530 in healthcare expenses was spent per person in the U.S., reaching a total of $4.1 trillion in 2020.
• The worsening state of behavioral health and substance use: About 32% of American adults with mental illness also experienced a substance use disorder (SUD) in 2020.
• The need for greater collaboration to drive efficiencies: About $1.4 billion in savings from collaborative quality initiatives (CQIs) has been saved through increased payer-provider and provider collaboration.

All these factors result in increasingly complex challenges for health plans, even as many shift focus to the goal of value-based care – high-quality, low-cost care. One tangible area in which we see plans shifting focus to tackle this complexity is quality measures, specifically Medicare Advantage Star Ratings.

CMS has implemented changes in the Medicare Advantage Star Ratings system which have operationally and financially impacted health plans across America. Between 2022 and 2023, the percentage of health plans with a 4 Star rating dropped from 68% to 51%. This decrease subsequently causes significant reduction in revenue and bonus, decreased ability to provide supplemental benefits using rebate on bid, and loss of continuous enrollment.

To combat these unfavorable effects, the CMS made the following changes to Star Ratings for 2023:

• CMS will no longer universally apply the disaster provision as it did in 2022
• CMS will implement annual upper and lower limits, or guardrails, on changes in cut points for non-CAHPS measures beginning in rating year 2023
• CMS will remove performance outliers from the calculation of non-CAHPS measure rating cut points in rating year 2024
• CMS will update measures, including increasing the weight of Plan All Cause Readmissions (PCR) by 3x

With these new provisions, there is an even stronger emphasis on member experience and health equity to deliver whole person care to each member.

Succeeding in quality performance requires alignment between plans and providers – and the tools to enable improvement. Real-time, actionable insights hold the key to delivering whole person care to each member.

Because point solutions are difficult to stitch together, contracting for one solution that guarantees results is preferred by many and can benefit health plans and providers alike. Innovative technology can help to leverage Real-Time Care Intelligence™, extracting data and insights faster to improve payer-provider alignment and improve Star Ratings performance.

Real-Time Care Intelligence can especially help health plans focusing on the Transitions of Care (TRC) and Follow-Up after Emergency Department Visit for People with High-Risk Multiple Chronic Conditions (FMC) Measures.

The four components of the TRC measure include:

1. Notification of Inpatient Admission
2. Receipt of Discharge Information
3. Patient Engagement after Inpatient Discharge
4. Medication Reconciliation Post-Discharge

Trigger Event: acute and nonacute discharges on or between January 1 and December 1 of measurement year

The major component of the FMC measure is to calculate the percent of all ED visits for which the member had a follow up service within 7 days of the ED visit.

Trigger Event: all ED visits

To achieve ideal plan-provider collaboration and meet the TRC and FMC measures, here’s an example of an ideal workflow:

1. A member’s health plan and primary care provider have a shared understanding of open care gaps.
2. Member admitted to hospital, starting the clock on admission notification requirements
3. Member’s PCP is alerted in real time that they have been admitted. Notification is documented in the clinical record, and the PCP prepares for discharge planning, including scheduling any follow ups.
4. Hospital discharges member – starting the clock on discharge summary and follow up requirements.
5. Member’s PCP is alerted of the member’s discharge in real time – discharge summary is delivered within two days and provider documents receipt of notification and discharge summary in their EHR.
6. Provider follows workflow & next-step actions to schedule a follow up visit, complete Medication Reconciliation, and document within 30 days.

These quality measures that evaluate transitions of care and post-discharge follow up will present a big opportunity for health plans for 2023.

Payers and providers should investigate technology partners that not only surface care gaps in real time but engage providers and their staff. Investment in real-time reporting and analytics can be used not only be used for enhanced payer-provider collaboration, but also to better enable member experience via coordinated care.

Is your organization looking to leverage real-time insights to improve Transitions of Care quality measures? Contact Bamboo Health today to learn more.

We spoke with Kelly Lannutti, DO, the Director of Clinical Transformation and co-Medical Director of Mobile Integrated Health (MIH) at South Shore Health, a not-for-profit community health system serving Massachusetts. Dr. Lannutti shared how Bamboo Health’s Real-Time Care Intelligence™ helps coordinate care and drive improved outcomes for at-risk patients within the community.

Please introduce yourself, Dr. Lannutti. Tell us a little bit about yourself.
I am a Family Practice physician who is passionate about value-based care and innovative care delivery models.  As Director of Clinical Transformation at South Shore Health, I am responsible for the clinical programs within our population health framework including ambulatory case management, Mobile Integrated Health, Hospital at Home, Advanced Illness programs and remote patient monitoring.

Who is South Shore Health? What differentiates you?
South Shore Health is an independent, not-for-profit community health system offering primary and specialty care, hospital care, home health and community care, emergency and urgent care, and preventative and wellness services.  It is the parent organization of South Shore Hospital and South Shore Medical Center and includes the South Shore Visiting Nurse Association. Through our extended partnerships with Brigham and Women’s Hospital, The Dana-Farber Cancer Institute, and Children’s Hospital, South Shore Health is committed to offering community-based, exceptional care that the people of our region deserve.

Who does your community consist of? How diverse is your population?
As Southeastern Massachusetts’ largest independent health system, South Shore Health serves more than 1.2 million patients. South Shore Health’s main patient base draws from 27 municipalities within Norfolk and Plymouth Counties, with the core service area ranging from Quincy and Braintree to the north, Brockton to the west and Kingston and Pembroke to the south.

You offer Mobile Integrated Health (MIH). What does that consist of?
Mobile Integrated Health (MIH) is a program utilizing paramedics to care for patients in their homes and communities as an alternative to the acute care hospital.  South Shore Health’s MIH program is the only health system-based MIH program in the state of Massachusetts.  Our team includes paramedics, nurses, PAs/NPs, dispatchers, operational managers and medical directors who visit patients in the community in need of acute services including IV medications, labs, diagnostic imaging, EKGs, wound care and advanced illness support.

What successes have you seen with MIH?
Since our launch in March 2020, our MIH program has cared for more than 3000 patients and completed more than 8000 paramedic visits.  During the COVID-19 pandemic, we mobilized our MIH team to provide COVID testing, vaccination and eventually treatments to patients in the home as a way to reach our most vulnerable populations.  Today, MIH continues to provide care to South Shore Health patients with a focus on preventing unnecessary ED visits and readmissions in a time where we are seeing record-high patient volume in our acute care hospital.  For South Shore Health, MIH has been a game-changer, enabling us to care for our patients at the right place, at the right time, in the comfort of their own home.

You also have an Advanced Illness Case Management Program. What does that consist of?
Our advanced illness ambulatory case management program engages with our most high-risk patients, both in person and via telephone, to support them and their goals of care.  Advanced illness case managers help to coordinate care for patients and work closely with primary care, VNA, MIH, palliative care and hospice teams.

Do MIH and the Case Management Program complement one another? If so, how?
Absolutely! Our MIH team works closely with our case managers to provide comprehensive care to our most at-risk patients.  It’s not uncommon for a case manager to reach out to MIH to coordinate a same day visit for a patient who is experiencing worsening symptoms and would benefit from an evaluation to avoid the ER.  Alternatively, the MIH team has unique insight into patient needs since they are in the home working with the patient and talking with the family.  If needed, the MIH team will outreach to the case management team to coordinate ongoing services or support for a patient.

Has tracking the use of high-risk, high utilizers been a challenge in the past? How do you track them today across both of these programs?
Tracking of high-risk and high-utilizer patients has always been challenging.  Patients often utilize multiple healthcare systems and providers for care, which can make it difficult to coordinate and cause gaps in communication.  Utilizing tools such as Bamboo, our MIH and advanced illness case management teams are able to get real-time alerts when patients receive care, arrive in an emergency room or are admitted/discharged from a hospital or facility.

How do you coordinate their care to eliminate care gaps, maximize the value of their care, etc.?
South Shore Health is committed to providing exceptional care to our patients. To eliminate care gaps, avoid duplication of services and assure goal-concordant care we have invested in programs such as MIH and advanced illness case management. Coupled with technology like Bamboo that enables us to coordinate transitions of care, we focus on identifying our patients that are most at-risk for hospitalization and/or readmission and proactively outreach to them when appropriate.  Following an acute event, our MIH and advanced illness teams can connect with patients to provide additional care in the home, transition back to the PCP or follow up on recommendations to improve their overall health and wellbeing.

Are there any patient stories that stand out to you?
One of the most impactful patient stories recently was a gentleman who had been identified for the advanced illness case management program due to his diagnoses and recent hospitalizations. Bamboo alerted our advanced illness case manager that the patient arrived in South Shore Health’s emergency department (ED), and she was able to contact the ED staff to coordinate care aligned with his goals.  Without her intervention the patient surely would have been admitted, but thanks to her real-time notification and outreach the patient was able to be successfully discharged home with MIH services instead, where he was cared for in the comfort of his own home.  The patient and his family were so grateful for the care they received and the coordination of services.

To learn more about how Bamboo Health can help your organization achieve care coordination, contact us today.