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Courtesy of Gateway Health Plan's Daniel Weaver, below is a transcript of his speaking session on 'Transforming the Quality Rating System Paradigm' to Build a Thriving Enterprise that took place at BTOES Healthcare Live - A Virtual Conference.
Transforming the Quality Rating System Paradigm
2020 has been a transformational year in the Healthcare space that has forced payers and providers to radically adjust process and strategy. As health plans scramble to implement rapid cycle improvements and modifications amidst constantly evolving regulatory guidance, it is essential that plans consider mid and long-term strategies through an Operational Excellence lens that enables continuous improvement and agile flexibility for sustainable and effective change.
Takeaways will include:
Excited about, we have Danielle Weaver, who is the vice-president of Medicare and Medical Quality Programs, joining us for the next presentation.
Then, after 15 years as a BPO, Dance served as the Director of Programs at Highmark Inc, where he led Medicare Star rating programs for over five years before joining the Gateway health team to establish a quality program focused on delivering a four plus star rating.
Their role expanded to include responsibilities across all government quality rating programs, quality improvement, and accreditation, and risk adjustment accuracy, and revenue management, with a focus on applying tenants of operational excellence and continuous improvement to the quality improvement space. Gateway Health Medicaid program improved to a four accreditation score in the Medicare program achieved, the company's first, for no Medicare Star rating than pleasure to have you here.
Really looking forward to this presentation, and the insights on how you can improve quality at the level that you have led the organization. Thanks for sharing your journey with us.
Thank you for having me.
So, uh, it's a pleasure to be here, and certainly have been a lot of great presentations up to this point. Looking forward to sharing a little bit about Gateway and what we do, what we've accomplished recently, and really how that fits into, I think today, the last couple of days worth of discussion.
So first and foremost, just a little bit about, you know, the topic today, really, quality. As a as a program, you know, we think of these quality rating systems.
You know, when I meet with most executives across the companies, the bottom line is that, in a lot of cases, they affect your revenue.
And when you really try to dig deep into the programs, you know, there isn't necessarily much beyond the surface level understanding of the programs, unless you come from that quality space. You know, you think you Chief medical officers, you think of the folks that really play in clinical services. But, the decisions that we're making, you know, in the last 3 to 5 years, really affected by the way that the government is making revenue so relevant to these programs, has really changed in a lot of ways. The ways that health plans approach, you know, what we do on a day-to-day basis. Some of the investments that we're making, some of the process improvements and changes that we make for a long term.
So, this is a great year to highlight our founding, what you do in that space, in this methodology, in any of these methodologies, in this mentality of continuous improvement, really can help make a determination of how successful you are for the long term future. So, I really wanted to use, this year, I wanted to use what's happened with ..., to sort of highlight the way that the government radically changes, how we have to focus, talk about what those programmatic changes are this year, and really what the implications of that mean. It's more about what does it mean for us, or the so what of it, if you will?
Then, a lot of plans are put in a position where you're making decisions. And, you know, some of those are short-term decisions. Some of those hopefully are no longer term decisions, but every decision that we're making as consequences, and so I'm going to use the practicality of what's going on this year.
And the successes that we've had recently, Gateway Health, to highlight how applying those larger principles as larger methodologies, The concepts of innovation. The concepts of continuous improvement.
Things that you've all been speaking about for the last couple of days, and that you've all heard about in the last couple of days, about, really can make an impact here, and show that quality has some rigorous demands. You know, it is not a forgiving. No spouse, if you will, and you really have to think exactly how you can be successful, but you have to do it in rapid fashion. So, I wanna have a little fun with, at the end, called, Coloring Outside of the Lines. It's really how we can sort of loosely apply some of these methodologies and think through the decisions that we're making, but do them with an eye on success.
So first and foremost, just to put it into perspective, who cares buys Gateway here? You know, Gateway health is a relatively large MCO. We service about 330 to 350,000 members. But what's interesting is we service that really sort of impoverished disadvantaged population. We focus on government programs so your Medicaid, Medicare dual eligibles that are eligible for both Medicare and Medicaid, we have exchange folks as well. But gateways part of a larger health system, or health plan, if you all are part of a high mark health family, Blue Cross Blue Shield.
So, while we're technically our own independent company, 50% owned by high mark, for some, my attorney health system. You know, we're very closely collaborating very closely working with sort of our parent companies to really try and help make sure that we're bringing holistic care, you know, throughout the state throughout the region that we play in.
And why it's relevant for this conversation, I think, is because if you look back on Gateways, History, Gateway has been a longstanding company, 26 years, 27 years in the market, but it's been sort of a mixed bag of performance.
And late in 20 18, the company made a decision a very strategic decision to really overhaul what we're doing. I was asked to come on board to help lead a portion of that effort in this quality space, and really transform an area that wasn't successful in the past. So a lot of what we're going to talk about, you know, towards the end of this is really how that, you know, what we've done and how we applied a lot of the principles that you've talked about and we've heard about the last few days to trying to make that successful.
So 2020 speaks for itself, this has been a crazy year for a lot of folks. You know, depending on what side of the healthcare space you're playing in, you've either seen more significant impact on the negative. Negative side are more significant impact on the positive side. You know, MLR is town for most health plans. As people are utilizing they're going in and receiving care. They're getting the preventive maintenance that they need. On the flip side, providers are bleeding, you know, they've lost revenue, you know, they're struggling to maintain their work. Hospital systems in some cases are strained, Others have made investments anticipating, you know, more severe impacts from covert than they had. In the biggest thing is, there's no consistency. There really hasn't been any one sort of solution, or one sort of problem that we've dealt with. It's really been disparate across the entire United States.
So, speaking about quality, and what does that really mean for us?
You will see my slides are word heavy. I put a lot of information on there so that you haven't, because I do know that these are recorded, and you'll see them later, so, should you want to view them, share them with somebody that's up to you. I'm not a person who's going to sit there and dreams. The gist of this, is that co-pay is a huge catalyst.
We've seen unprecedented change in 20 20 from the way that the rating systems work from what data is used to actually measure performance, to how we're going to actually affect the ratings, the quality, the measurements of quality.
You know, providers have been severely impacted everything from their workflows to their capacity to just being able to function as a provider, new, you know, sort of restrictions and precautions that has to be put into place. It's really changed their paradigm in terms of how do they continue to provide service. Telemedicine has emerged this year as a very interesting alternative, especially in the Medicare space, and even in the Medicaid space, in our state. At least, it wasn't heavily utilized before. So how it's utilized, what you can and can't do with it, how it impacts your quality rating results. This sort of, the whole picture has really been driven in a rapid forced change that, you know, wasn't anticipated. I've been at conferences over the last three years and I've heard telemedicine brought up as a question mark every year prior to this year.
Vendors are always curious to know what our health plan is going to do to sort of drive telemedicine. Is it ever going to be a thing? What CMS get to do, too?
Make sure that plans are, you know, and payers and everybody, you know, have the right processes that that providers can get reimbursed appropriately, that it makes fiscal sense for us to do this. And in 2020, everything just radically changed. all of the guidance that came down from the governments. The just pure functionality of it, if you will, the feasibility of being able to go into a doctor's office in the midst of the pandemic has forced an evolution in that part of healthcare that people were not necessarily prepared for proactively.
In addition to that, you know, there's a variety of other implications, You know, you think about supplemental services, You know, a lot of plans and my sort of, you know, space that I play inequality. You know, we're constantly looking for ways to supplement the work that providers are doing for the members that are either disadvantaged and can't get to their doctors. That deal with, you know, many of the social determinants of health, like transportation barriers, housing insecurity, food barriers. You know, there's just so many challenges that people face, that we're always trying to come up with innovative solutions and take those into market.
And what I think is really interesting is that you have, you've seen a forced shift of that, obviously, this year, just because of the fact that, you know, so many community based activities were just stopped.
In home services, were stopped, sort of.
No, disparately, I guess I'll use that word. You know, what, you'd see from one company. It was different from what you'd see the next. Because different folks who are sort of, you know, determining whether they met the definition of essential service or not, so some things that you may have relied on as a part of your strategy in the past were just immediately stopped and you didn't have an opportunity to continue those. So, this year's forced evolution, right? We've really had to think differently. And we've had to change, and then there's the longer term implication for chronic conditions chronic complications on there. Because we're seeing a lot of avoidance this year. Obviously, people are scared about going to the hospital. They've been scared to go to their PCP, or they can't get in.
And so some of those folks that deal with long standing chronic conditions: diabetes, hypertension, congestive, heart failure, any of these types of things you know that require maintenance care. Really You know, we're seeing exacerbated episodes, where people do show up at a hospital because they haven't necessarily been getting the care along the way that they should have. And how we are reacting in the healthcare industry to try and do to fix that is obviously forcing a lot of interesting change.
So after some some Telehealth notes up here, not because I will dive into this and if you're going into detail just because it may be relevant, you may be interested in understanding it.
CMS has really transformed what they've done with telehealth. It's a prime example of how there's been a reaction to this pandemic in a way that has forced unexpected change.
And it's interesting because they've really, you know, allowed for a lot of things that they have in the past.
For any of you that are familiar with the risk adjustment space, you know, CMS is very interested in making sure that we provide the most accurate depiction of our members through claims and through encounters. So that you know we are reimbursed inappropriate rate to provide for their care. In the past. Telemedicine really wasn't an option for that and they've adjusted a lot of their processes, which means massive financial implications to health plans, both in terms of how do they actually go out and capture this information? How do they, you know? ..., those encounters as well as you know making sure that on the backend that information is being ingested in a way that is sustainable inappropriate to actually generate the revenue that you're expecting. I'm not going to dig into this detail more as we get into this slide, on my really dive into it. But I wanted to highlight, especially if you focused on, kind of on the lower right corner, there is, there's a lot of a lot of implication to what can be done with Telehealth or telemedicine.
In the past, you really have very limited options. And, it was basically just, for lack of a better term, say, you know?
Wellness checking. I mean, if you had a scratchers scratchy throat or something, you could do a basics. You know, encounter, and especially in that Medicare space, what we can do with them now is really dramatically different. It affects a significant portion of the measurements that are part of these various quality rating systems, and it affects the way that you can influence care.
It's dramatically different than it's been in the past.
So, really, what's it mean? What are the implications, Why do we care?
When you're thinking about quality, the landscape of health care, we usually get a decent sized budget.
For those of you, especially on the financial end, or if you play in that sort of IT and operational space, that support programs like the quality programs, there's usually a lot of asks. We're constantly, you know, bringing in some new vendor, or asking for some new enhancement to the system. We are, you know, challenging the sort of status quo, if you will, of how we've done things in the past and forcing, you know, a need for something new.
one of the biggest spaces. There's membrane gate.
I'll talk a little bit more about some of the quality implications in a second, with the programmatic changes this year, But memory, engagement as a whole, is really a heavy focus. Within the quality space, you know, we want to provide a holistic solution for our members. We want to make sure that we're providing the best possible service, the best possible quality of care. But, what's happened this year, The changes in the landscape really affect that in a much different way.
And that that infiltrates, every element of the operations at a health plan, everything from how you enroll your people, how you market to get a new members, and how you try to maintain. and, you know, keep the folks that are doing well, or that you want to have on your service that are generating revenue for you. It affects everything from the to the systems that you use to manage customer service. How accessible data is to your internal teams, as well as to the members themselves, decisions that you make around you know, how to use technology, you know, where are you going to go into the digital space? All of that is driven from a mindset of member engagement. And they just has significant downstream implications throughout an entire enterprise.
Coven has had different impacts across the board for our members. How We do things is different, especially at the beginning of this year, and you know, that sort of April and May timeframe, we saw a massive shift to telephonic and digital outreach to members. A lot of it was compassion outreach. It was, you know, engaging with people, just to make sure that there are K, making sure that, you know, they had services. It's not unlike what you've seen from some companies over the years and disastrous situations when a hurricane is asked, when there's been some type of, you know, catastrophe. The wildfires, et cetera, you know, good health plans or, you know, creating programs to make sure that we engage with people in a way that's meaningful and impactful for them. And in some cases, it's just to be, you know, a good person, there's no no ulterior motive.
We're doing something to make sure that we're taking care of our members, because we genuinely care, um, scope and impact, that everybody differently as well. So, the decisions that you might have to make it, your health plan, might differ significantly from one state to another, from one region, to another, Simply, because you may have seen more or less strain more, or less provider impact, you know, more or less, more, or less limitations to the, you know, impact within your communities. But one of the one of the most alarming statistics, certainly, one of the most concerning throughout all of this, is the impact of providers. You know, roughly 50% of all the systems out there. You know, in the sort of the midst of this, I'd say, it was maybe the june ish timeframe June into July, more indicating that, based on restrictions in their states, based on the reduction in, you know, utilization from people. Avoiding doctors. Because A coven 50% of the systems out there had to furlough employees.
There are some of the smaller practices that haven't even been able to re-open it, or some folks, especially that are a little, you know, more more intensive interaction that have had to push people to other facilities, because they don't have the wall lift. So it really does have significant implications to our providers. And that has significant implications back to us maintaining an active provider directory, making sure that we understand how we deploy and utilize our resources. There's really a lot of impact to us.
But all of those things are sort of your day to day operations that have implications down inequality.
But at the end of the day, government has had to step in. And basically say, OK, we've put a lot of your revenue, it's actually 5% of your revenue for stars Reading program as an example.
It will ask, based on this rating system.
However, there's a lot of things that would normally be going on that we just can't give you credit for. Right now, we can't even focus on.
So, through a basics, stars, one-on-one basics because what I found from a lot of leaders out there, a lot of folks who complain the quality spaces. You kinda get it, but you don't necessarily know the details. Certainly. don't insult anybody's intelligence. That's not the point. I just thought it might be useful, at the end of the day, this rating systems comprised of, a significant number of, measures were usually in the mid forties to high forties, you know, and they cover so many different topics. So, when you think about it, ... is a, it's basically your preventive care.
It's, you know, the stuff that we're doing to get people out for cancer screenings, and, you know, basic exams, and managing their diabetes, and things like that. But, we also do member surveys. So, think about, you know, person getting a survey in the mail right now, being asked to answer questions about their mental health, or, you know, physical health, whether or not they have access to the doctors away that they believe they should or are they getting seen as quickly as they believe? They should.
There are just so many dramatic implications based on what's going on right now, too, with the quality programs, That it's, it's, it's important to understand what they really mean.
Putting 5% of your revenue at risk is a challenge. But the biggest thing I would like to tell anybody, when we talk about stars as a program, as an example, and I see it consistently with the ACA's quality rating system, as well as our Medicaid pay for performance programs. If you're in one of those states that your state uses, that is that the reality is the clock reset every year.
These are not a program where you can establish something and now you've got a 3 or 4 or 5 year program.
Every year the set of measures changes slightly. Something is more important than it was the year before. Something goes away that you've invested time and energy or you've built a system to support.
They add in something new that forces additional change just by nature. Quality is creating a scenario where we're constantly forced to try and improve.
And are, you know, to sort of exemplify that there are actually two quality improvement measures within the quality rating system for stars ratings, and they are the highest weighted most impactful measures of all. And they literally measure how well you have improved at an individual measure basis over prior years.
So for the folks that don't want to know the nuances, don't need to know the nuances of what every measure does and what everything does.
one of the biggest things to keep in mind cloche resets every year, and the most important element is we have to continue to get better than we were before.
Now, spread that out across the fact, that there's over 600 Medicare Advantage plans that get, you know, are competing for star ratings, and an annual basis anyway. And now, all of a sudden, you realize you're being scored against the curve.
So while you're trying to improve, while you're trying to do a better job.
Everybody elses as well.
So big impacts this year, again, I'm not going to train the details there, in case you want to reach refer to them if the spur something, and you want to take it back and talk to somebody in your own organization.
The reality is, is they've changed the weightings on a handful of controlling blood pressure is a great example. Um, no, it's jumping up to a three-way match.
So you think about, you know, hypertension out there throughout the throughout the United States is an issue. It's one of leading impactful you know, conditions that influences other things and can affect, you know, obviously mortality. So, you know, maintaining and actually managing that level of control is what, what they're concerned about and a tripling, the value of that. Surveys, the ones that I mentioned earlier where you're getting asked questions about how happy you are with customer service, have your with the access that you're getting to your provider. If you're being seen as quickly as you think you should be seeing. These are all perceptions. These are all questions about how a member feels about what your health plan is doing. How will you manage your providers?
They used to be weighted at 1.5.
You know, their measure was worth 1.5 times as much as an average measure.
Well, in this new system, they're jumping up to four times the weight of a single measure.
So there's eight ish, 8, 9 10, you know, CAHPS measures, it varies from time to time, let's call it aid, for simplicity sake.
You have a significant portion out of that 45 to 50 measures that are all increasing in their value to four weightings. That's happening for 21.
There was a survey that goes out that asks people about their mental health and their physical health. That was supposed to come out in the summer, or it was supposed to come out in the spring. We believe that to summer. So now, seniors, especially these people in this Medicare Advantage population that are 65 and older, for the most part, are getting a survey asking them whether or not they feel that their mental health and or their physical health has improved. And they're being asked to rate that in comparison to how they felt two years ago in the midst of a pandemic in, the midst of although the racial disparity crises that are going on across the United States.
In the midst of one of the most interesting political landscapes that we've seen in many years, that survey's hitting our members, doorsteps.
The good news is they did give us some flexibilities this year. They actually allowed us to expand the over the counter benefit options that we have and how we treat pharmacy, but at the end of the day, all of this, it just drives us to course correction.
Whatever we thought we knew, coming into the year, We don't know too much has changed, And this is where I really argue.
This is where, what we do in the quality space, especially the approach that I've tried to bring to gateway health that we also implemented is really a mentality of continuous improvement.
Um, you know, it doesn't matter which methodology. you, you choose to, you know, like I said earlier, they're really, really all applicable, And I think it comes down to preference, Think it comes down to the resources you have available.
It comes down to, you know, what you're comfortable working with in your culture, But at the end of the day, what changed most dramatically? The reason we moved gateway up into its First four ***** rating and started to earn a quality bonus payment for the first time is: we infused it throughout the entire DNA of the company.
So, the short game is, how do we fix the things that are going on right now? And this was a great year.
This is just an example, the next page or two is just visualizations of this to try and help, you know, sort of facilitate the understanding of what we're talking about, know, their scales, You know, you're making decisions based on, you know, where, within a scale these things fit, Where you invest in your resources re-invest in your toddlers. Are you investing your time and your energy? And, you know, culvert is forced to change.
And it's interesting because it's the most turbulent time we've seen in the quality rating space since way back in 20 13, and for any of you that weren't intimately involved then, that was another catalyst here. CMS basically said, at that point, if you don't earn a four star rating in their 1 to 5 rating scale, you don't get a quality bonus, zero dollars.
And that made significant impacts, where I know of companies that are seen over hundreds of millions of dollars of impact, because they dropped half star rating, one year, or they just didn't earn a four, and they thought they were going to.
So, again, I'm not going to dig into this. The, the reality is that this is, Catalyst is a catalyst for change. It's making an impact.
So we're in a situation now where, you know, we had to wait.
We had to sit through what was going on with ..., we had to wait until start. Things started to re-open and we understood what States were going to allow. The Federal Government was going to allow what guidance was coming from CEC or vendors comfortable with were able to improve their own processes and set up the right protocol so that they can actually support us.
And we've done a variety of things little footprint to try and, you know, make the rapid changes here that we think will be impactful. But at the end of the day, the most important thing, I think is really that it's got to be about the member. Every decision that you're making in this type of an environment, really has to be about putting remember at the center of what you're doing and making good decisions for them. Through this quote, on the right-hand side of this, you know, there's so much chaos going on, right?
How can you help create calm in the store and what are we doing to try and influence them.
So, um, here's where I want to stop and pause for just a little bit and play.
So, I had this information up on the screen. And that's why I figured you can see it maybe a little bit more. You know, I tried to grab a couple of the different major approaches just to showcase a little bit about how we'd be looking at these things that we're doing in spring capacity to see what would it mean. Right. So, you know, you think of Kaiser site. You know, it's obviously a cycle in use improvement, You know, and there's a variety of principals within that. And obviously, I'm not gonna sit here and drainage one, I'm talking about how each one of these little things was born through that, because that's not how we did it. But really, it's more about the questions you're asking, right? You know? are we establishing these partnerships with flexibility to test the solution measure? Analyze it, you know? Are you just slapping something in a market or as you're preparing to soft something in the market? Are you thinking through all of the questions that are going to be answered, to make sure that you can actually make a determination as to the success.
I will tell you that within the quality improvement space, we have to be able to act and re act more rapidly, then many other areas.
Because if something's not working, you don't have the luxury of waiting to see 12 months, 18 months, two years, whether or not some things make the impact that you need.
You have a test that you have to take with the government every year, and you get, basically a 12 month window to either earlier score or not earn it.
So, you know, how are you doing these things in a way that you're able to measure them, that you're able to analyze them, and you can then adjust accordingly.
I think one of, one of the things I love from the last presentation, because you talked a lot about culture, that I think is really essential and notes of, sort of an underlying principle with all of these, is, How are you involving employees? I loved the scenario that was just presented, when you talked about the first week being, you know, being at your company, and you were challenged to come up with 100 innovations.
Hundred percent agree that people that sit in the room every day, that know this stuff in and out, they get stuck inside their own box. one of the biggest challenges that I have faced in the last eight years of doing this specific type of work is starting to build new relationships and challenge the paradigms, if you will. With people who have been embedded in quality, quality improvement, even parts of operations for just years, have a way of doing things, is difficult for them to necessarily think outside of the box.
But I will tell you that once you pull in a massive group of people, once you can bring to the table, all of the variety of potential stakeholders are ..., you know, people that are willing to, to think and help them, or ask them to be a part of the solution process. Insignificantly changes both the ability to see different perspectives as well as the innovation that you get out of a group. You don't have the same 2 or 3 people kind of beating their own drum, you start to have folks challenging what somebody else's perception looks like, or adding value to something that maybe had legs, but wasn't really ready to sprint yet.
Lean principles. Similar concept, right?
You know, what's the defined value of the short-term mitigation? Does it exist beyond just this crisis? Are you solving for a micro problem microcosm of an issue, or are you solving for something that's bigger implications, and can it be easily mapped, tracked, adjusted? one of the core principles with my team.
Anytime we're launching a new initiative, I don't care how small it is and how rapid we have to go out, we need to build the process. We need to make sure that it's there. We need to understand what the steps are. And we need to make sure that we can document those, because if we can't do that, and we're forgetting something, we're likely to miss something, or we don't have a way to scale that in the future, collaboratively with the other departments that depend on us and that we depend upon.
And the most important lines, very neatly with the Kaizen principle. We have to be able to measure performance. How can you analyze what's being done throughout the different stages? How can you make sure that you are pursuing perfection, even if you're not necessarily perfect at the time?
Then, ultimately, how are we continuously re-evaluating all this when you think of operational excellence? Right? You know, all intimately as your leadership involved, how are they supporting this from the top-down? How, you know, what does the culture of your company look like to support these rapid changes? You know, I can think of many years in various different industries. Where, you walk into a year with the budget, and you have a laundry list of items that you're supposed to do. And deviating from that budget becomes the most painful process that you've ever experienced.
Quality improvement is a space that does not allow for that rigid approach. We have to have that flexibility, and that comes from the top down. My CFO isn't on board with how important quality is. If my executive leadership team, that we meet with and share an IDE regularly, is an on board, with rapid assessment and improvement.
Then, we're going to be mired in whatever lack of success is going to result from that for an ongoing basis.
Um, there are long term implications of this, right? Again, I'm not going to train the details there here, just in case you're interested. You know, there's a lot of things that happen when we're making short-term decisions, and if you take the right approach, if you're thinking about things in a, you know, a bigger, longer term picture, then, you can account for some of those are Simple checks and balances processes, right? You know, think about what's the risk management compliance, especially in, the government program. Space is critical, you can't make a decision that doesn't check enough of the boxes to be able to move forward.
You have to make sure that whatever you're doing rapidly, you're prepared to adjust it, but that you're creating the right documentation, that creating the policies, that you've developed, everything, that you should, have any program, you obviously have to account for that in your planning and your implementation processes. Data is integral to any success, You have to make sure that you have that information from the get go that you're planning for it. I, in the past, I've seen people launch a rapid program with the vendor and not even think about how are we actually going to get the data on the backend. And then getting that data becomes more of a hassle more of an issue than it actually was ever needed to be. If we had just stop for NaN to say, Hey, we're going to need these five things, are critical to our ability to measure success.
If it's a good idea, if you launch something rapidly that really works well, there's nothing worse than finding out it's not scalable or it's not sustainable.
Think through how you're building it from the very beginning to make sure that the, that quality improvement mentality, that continuous improvement mentality, is really infused into the DNA of what you're doing. So that you're making smart decisions along the way.
And again, I'm not going to drain all these. You can understand cost optimization becomes an issue a longer the program runs. You need to find efficiencies, et cetera.
But at the end of the day, because I know we're almost out of time, I wanted to talk just briefly about coloring outside. Right?
In short, what I would say is, a lot of these principles, a lot of these program mentalities, you know, it doesn't matter, or can lean, if you're talking?
It doesn't matter what you're looking at.
It's the end of the day.
Fundamentals of many of them are very similar, because the concept is about making intelligent decisions, and having good processes, so that you can continuously re-evaluate what's being done. And take actions that are meaningful, that are taken with purpose.
So I threw the lean construction on here, you know, the simple, you know, plan, do, check, check, and act as a simple guideline to think about this within the quality space, right? We have plans. We have long term planning cyclists for every quality cycle. The government gives us insights sometimes, you know, six months to a year and a half, two years even before they're gonna make a change. So we have time in some cases to think through and long term plan for that.
At the same token, we plan for the fact that we're going to have to rapidly adjust and replan throughout the course of a normal year. A lot of what gets done in the quality space can't be that sort of traditional foundational strategic directive. But at the end of the day, when we're making any of those strategic, foundational, you know, decisions, we should be thinking about the quality improvement space. And from the quality improvement space, as we're making decisions, we should be thinking about how they influence those other areas, those other approaches that are being taken throughout the company. No.
There's nothing more that I can, that I can highlight in terms of quality improvement, for making sure that we're applying these types of mentalities, to having that mindset, building the culture with your leadership and throughout the organization and in a very matrix. Way, honestly, very collaborative way.
That we need to be able to constantly or's correct mid cycle quarter cycle, every month, every week.
If we have that continuous process of checking to see whether or not what we're doing is working, then taking action to correct that process, we're moving in the right direction. You know, I threw the basics here to suggest how we approach this, how we look at it. You know, one of the one of the things I said is don't come to analysis paralysis. I love to say that.
You have to take smart actions, but, you know, quality doesn't allow, And, a lot of cases for the long game analytics, you still have to have those. They're critically important to the evolution of your health care plan, to the products that you designed, to the processes that you establish and build out with your providers and your members.
But at the end of the day, there is a need for rapid assessment and rapid cycle improvement in this space. Because if you're three quarters of the way through the year, and I'm just gonna make numbers up, you need to get to 87% on a metric. And you're sitting at 54.
If you have good analytics, you might say, that does good analytics, are telling me, I'm only gonna get to 67. I'm gonna fall short.
If you aren't doing something now to change it, and you're just accepting that we're going to fall short this year, but let's figure out how we're going to fix it for next year, you've already failed Quality improvement within these Medicare rating systems, within your state rating systems. They don't allow for that level of long term decision.
Um, so, I'm going to just skip over this. It's there. I think everybody, on this call is probably familiar with continuous improvement cycles.
And really, just, I'm just saying, you have to apply that to what you're doing, the quality space. And that was the difference maker.
If nothing else, in terms of improving performance, we routed process, We implemented the foundational changes to the operating model, into the support structure from our leadership at this company. And then we've adopted this methodology, continuously re-evaluate what we're doing and make good decisions for the future. Are we doing it well? Should we stop something? You? Should we start something new, or should we modify what we're doing? And we constantly are forcing, you know, innovation ideas, innovative ideation, trying to figure out what haven't we thought it?
End of the day, what I wanted people to take away, you know, it's just basically make smart decisions. You have to, you have to build this into your organization. Quality needs to be a priority if you want to be successful. It has to be infused across the board, right, Your entire leadership team.
When you make decisions, when you're repurposing resources, dollars, time, energy, whatever, is the be. Do it with purpose. Make decisions that aren't just, that aren't just reaction.
And involve everybody, devolve everyone across the country. Because when you do that, you create the opportunity for innovation. You create the opportunity for, you know, good partnership standardization across all processes and all people. And it allows you to then, you know, find that right balance in what you're doing. You're choosing things in your approaches that are longer term decisions that have longer term implications, even when you're doing them and rapid site.
So I know that we're about out of time, and I'm going to shut up now so that if anybody has a question, I can do my best to try and answer.
Then, there was very good, very, very good, though, thank you so much, very comprehensive view of your journey on improving quality ratings, ratings for their organization. Really fascinating. You talk about so many different areas that are relevant today, but even before Cove in 19 hit, the Summit, one of the themes of the questions that emerge here have to do about your journey for improving the quality rating system at the, at your organization.
So, we can tell a little bit about when you started that, what level you're at to start, and then, you know, as you bring it up to this four level, was that journey like how long it took, and what were some of the main, main changes that took place to allow you to get to the highest level, to the higher level?
Sure, so, um, Gateway, being performing at a 3.5, on a scale of 1 to 5, which puts them just short of the money, challenges, that is that, you know, there's a range within there that urge you that 3.5 and we were trending down toward dropping to three.
For three years, our performance was at the lowest end of the scale that earns you a 3.5 star rating. So they were at risk of dropping.
I came in early 2018 in sort of a consultative capacity from highmark to really try and help our little sister company improve. And we put in some sort of basic, foundational improvements to the, just the day-to-day operations.
A couple of measures, what I would call, and what I normally, designated as the path of least resistance. What were the areas that would be the low hanging fruit, you know, whatever analogy you want to use, one of the things that we could fix most rapidly.
I joined the company in August of 2018.
And when we got our rating in the fall of 2019, we just cross the threshold to a four star rating.
So those foundational things we've done at the beginning of 18, coupled with a lot of really intense work at the end of 18, and then into the beginning of 19, was able to push this over the threshold. This year, in 20, 20, you know, we're in a scenario, where obviously A lot has changed. We've seen that, continued to improve performance improvement growth from the time that we started. Until now, we've we've improved almost an entire star rating within that system. We, you know, we've moved toward about 4.5 star threshold. We're not quite there yet, but, you know, we've maintained that for with continuous improvement, so across the board, you know, if my raw score before, what's called a 3.75 is what it takes to get you to four. We got a 377 or 370, We've jumped up to basically over 39, and change, Or almost a four point.
What do you think was the, maybe the most important factor, or maybe a couple of factors that were the biggest levers for increasing the score?
So, I'd say the two biggest levers that we, that we have for improving the score, The first was cultural evolution.
We actually, you know, went through a massive overhaul with our C suite and with leaders across the company around the time that I joined an 18. And with that, it started a year, just a foundational change in the way the company approached quality. We had CEO level down support. With that, we ensured that there was good corporate communication, education awareness. We really started to infuse quality awareness into the company's DNA, to make sure that everybody was aware of what's going on, and that all leaders were sort of speaking from the same playbook.
And then the second thing would really be the design of a effective playbook.
You know, I, the director of my programs, is a six Sigma Black Belt, and my entire team of folks that improves quality performance, our project and program managers that have disciplines in various areas, like either, you know, marketing or provider office management and things like that. So that they sort of can bridge the gap between the healthcare world as well as this. Like, you know, traditional quality improvement and continuous improvement space bounding what we do in those types of principles allowed us to make better decisions and to build a playbook based on where we had deficiencies so that we were targeting the areas of underperformance. In a way that was going to build sustainable, continuous improvement.
Terrific. Terrific. Want to relay a couple of comments here, such Harvey, one of our participants is saint Great presentation. Thank you for sharing with us. I have a question from William Fuller, who is in Oregon, and William asks, And ..., for that, the forces of markets and regulatory agencies are, driving us to the same quarterly results, operating modes, as other enterprises have health care organizations become a lot more like, you know, for-profit enterprises in the quarterly results approach.
I think that's a very fair assessment. I don't know that I was directly trying to infer that, but, yes. I would argue that is true. You know, there is so much of a financial implication to a health plan. Even those of us that are, you know, we're 100% non for-profit, because what happens is if we lose that funding, if we don't earn that quality bonus payment from the State or from the Federal Government, that significantly impacts the products that we can then offer to our members. So, that impairs our ability to be competitive in the market on an annual basis. When we recruit new membership. Or you know, try to retain the membership that. We have is significantly impacts all of the things That then create the budget dollars to invest in you know system upgrades and or platform. You know improvements and all the things that we need to do behind the scenes to be successful.
Very good. Daniel for your presentation looks like this for with the pandemic and everything that happened. It seems like this fourth quarter is like incredibly busy for you in the organization I can only imagine. And probably with 20 21, whether or not we have an effective vaccine or not, you know, there's a lot of uncertainty. And just, we have about a minute left here.
I mean, how do you plan ahead? How are you moving with the organization for a missed so much uncertainty?
We're focusing on the things that we know are certain, obviously, trying to maximize those, but we're really focusing on the member. I'd say right now, we know, because the weighting of the members is going to change those, those survey measures, that perception issue. We're really trying to hone in and focus as much as we can there.
But as we're thinking about the programs that we implement over the next couple of months, as well as what we do into the first half of next year, we're thinking about flexibility, agility.
How can we potentially deploy something that if we had to delay it, it's not going to cause any significant impact. Or if we had to move it up and the schedule that we can do that easily. We're trying to think from that mentality, as opposed, you know, think of it more like a, you know, mobile clinic out in the community versus brick and mortar office. We're trying to move toward that mobile flexible environment with every decision that we're making, and the less grounded in that stationary sort of rudimentary process.
Very good Daniel Weaver.
know how busy you are So much ahead of you coming up and the great presentation. Thanks for sharing your insights, experience and the and a lot of great practices with our global audience today.
Thank you, ladies and gentlemen, That was Daniel Wever from Gateway Health.
So a real pleasure to have Dan with us, and the very comprehensive review of the quality rating system and how that drives organizational performance and organizational behavior. So very, very interesting tool to witness that. Our next guests at the top of the hour will be is Mohamed Money a senior executive and leader in health Care. And he is going to talk to us about Community Wellness in the midst of a pandemic and the How to Address the Social Risk factors on a community level. So a very interesting review of the impact of a coven. And in Health, from a community perspective. So, we'll see you back at the top of the hour.
Thanks for engaging with us in the sessions. Thanks for the great questions. If you have additional questions or comments, go onto LinkedIn and type, or make the comment there under the posts that we have for this conference. And I look forward to seeing you back again at the top of the hour, Susan?
VP Medicare and Medicaid Quality Programs,
Gateway Health Plan.
Daniel Weaver spent the first fifteen years of his career advancing through various departments at an international BPO organization. With experience managing multiple disciplines including analytics, business development, operations, financial modeling, and performance management, Daniel advanced to the Director of Analytics and Vice President of Corporate Planning prior to accepting a role in the Healthcare industry with Highmark Inc. in 2013.
Dan helped establish and grow a Stars Quality organization within Highmark, serving as the Director of Programs and successfully achieving 4.0+ Stars ratings for over 5 years. Dan joined the Gateway Health team as the Vice President of Stars, Quality, and Risk Adjustment. In his first year at Gateway, Dan led the company to its first 4.0 Star Rating, improved the NCQA Accreditation rating, and implemented a complete organizational redesign.
Throughout his career, Dan has overseen the development and implementation of analytic-driven and customer-focused programs. Leveraging deep analytics expertise and a strong focus on team development, Dan has created methodologies and infrastructure that drive consistent results. Dan is an industry thought leader that believes in challenging the status quo and embracing innovation.
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July 11, 2022
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