The 9th Annual RISE Star Ratings Master Class next month in San Diego will provide health plans with cutting-edge strategies they need to boost their Stars scores. RISE talked to two of the presenters, Angela Perri of UPMC Health Plan, and Dr. Tracey Veal of Aetna, to learn more about their sessions and what steps they suggest health plans take to help improve the quality of care and the consumer’s overall experience.

Integrate consumer data with clinical and claims data analytics

UPMC is an integrated delivery system based in Pittsburgh that includes a hospital system, health plan, and is closely affiliated with Carnegie Mellon University and the University of Pittsburgh. This structure has allowed the organization to analyze how it can improve the health of the person and not just the condition or recent episode of care, according to Angela L. Perri, MBA, AVP Medicare, SNP & STARS, for UPMC Health Plan.

It involves gathering different types of information, coordinating care differently, and influencing providers so they look beyond the patient’s condition.

“What we are doing is creating a different kind of health profile for our members,” says Perri, who will discuss the health plan’s approach at The 9th Annual RISE Star Ratings Master Class, which will take place Dec. 11-12 at the Fairmont Grand Del Mar Hotel in San Diego. The health of the person includes his or her family, social structure, as well as the condition. But the condition isn’t the sole or primary focus, she explains. The organization integrates the information with other data, so the clinical team receives a more holistic view of the patient.

“We consider what else is happening with that person and we treat those factors equally. This provides care teams with a different view of that person to achieve better health. The strategies they are employing and the types of interventions are now driven by very different data sets and profiles,” she says.

This new predictive model and focus on care has changed the way the organization tracks quality. The result, Perri says, has also had a dramatic impact on Stars and quality scores.

Perri will discuss UPMC’s strategy and what it means for quality and real population management during her presentation. Meanwhile, she suggests health plans that want to consider a similar approach begin by answering these questions:

  • Are you capturing enough information on your members?
  • What information are you presenting as well as taking from your network of providers? Is it condition-centric or are you getting a greater view of patients from the network? If not, how quickly can you start to get more information about your members, so you can offer providers a better view of their patients?
  • Does your system present information in a way that allows you to represent different facets of members for your quality teams? If not, are there tools, such as data visualization tools, that you can use as an interim step to surface information while looking for systematic views for platforms?

Map the patient’s journey to better understand the member experience

During the Master Class, Dr. Tracey Veal, Ph.D., senior director, strategic programs, Aetna, will discuss how journey mapping can help health plans navigate the member’s experience so that they can engage the member more efficiently and provide interventions that will improve outcomes.

Veal says her experience with journey mapping is based on her work at multiple health plans and with different health care settings, including clinics, hospitals, and the community. But she also draws on her personal experience of navigating the health care journey for a group of family members from the same generation who have diabetes.

Plotting each family member’s experience led to several “aha” moments, according to Veal. The first realization hit her when she learned that the diabetic relatives, who were also amputees but otherwise relatively healthy, went to the same family doctor and never consulted with other specialists.

She then looked at the cost implications involved with their care. “Since I’m an insider at the table, when I do an evaluation of patients and members, I would look at the highest cost patient for the hospital, health plan, and doctor. And it was always a cohort of diabetics who would rise to the top. It pointed to the fact that we need to evaluate and target and segment the diabetes population early and often,” she says.

In the case of Veal’s family members, she was able to make sure that her diabetic relatives received specialist care from endocrinologists, podiatrists, or vascular specialists when it was appropriate and avoid another amputation.

Often, Veal says, when organizations aim to manage the health of a patient population, they focus on a certain aspect of the health care experience, such as patients who frequently use the emergency department for care. But it’s most helpful to look at the patient’s entire profile from all the points of care so the health plan can determine total costs and intervention opportunities, she says.

Veal suggests that organizations create a cost profile on members that looks at all the patient encounters, including hospitalizations, pharmacists, and primary care and specialist visits. “What’s compelling to me is going beyond the medical record and doing a journey map to that high cost, high chronic member,” she says.

The health plan journey map helps to ensure there is consistency and continuity in practice, according to Veal.

“If you don’t know the top five members in a diabetic cohort who are the cost drivers, then you need to do a profile on those members. And then you need to know what their similarities and differences are to determine if you really have a pathway. And while I used the diabetic condition because of the personal implications, you could do it for any condition like heart disease or COPD,” she says.

To learn more about these sessions and the agenda planned for the 9th Annual RISE Star Ratings Master Class, click here