[00:00:00] Stacey Richter: Episode 463, "Medicare Advantage Policies, Which Will stay and Which Will Go Now". Today, I speak with Betsy Seals.
Introduction to Medicare Advantage Policies
[00:00:26] Stacey Richter: Every Gen X'er listening to this is going to be singing that Clash song in your head for the rest of the day. So, let's turn our attention to Medicare Advantage Policy. And on the show today, I grill the one and only Betsy Seals to find out which policies she thinks are going to stay and which are going to go. Obviously, this is very much in the context of a new administration and also just other things that are going on.
To listen to the episode or read the show notes with all mentioned links, visit the episode page.
Overview of Key Policy Areas
[00:00:52] Stacey Richter: But today we talk about the following four stay or go policy areas.
Deep Dive: Medicare Advantage STARS Program
[00:00:58] Stacey Richter: Here's the first policy area we talk about changes and activities within the Stars program. How will the Medicare Advantage Star program change or not? Not only with this new administration, but also there are lawsuits and how they will impact the goings on moving forward.
Risk Adjustment and Government Oversight
[00:01:18] Stacey Richter: Second policy, will it stay or will it go, that we talk about is risk adjustment and all of the activity in government oversight and focus on recoupment of improper payments as kind of the overarching bucket and what will be the incoming administration's method around risk adjustment. This is certainly on many people's minds.
AI in Medicare Advantage: Opportunities and Risks
[00:01:39] Stacey Richter: The third will it stay or will it go policy that we discuss is the use of AI, artificial intelligence, by Medicare Advantage Plans. What does the appropriate oversight of the use in AI look like? Lots of talk about those prior auth AI algorithms and the high levels of denied care.
A big topic of everybody's collective mind is looking at how to ensure that oversight is appropriate and that we're using AI for good and that it's not having any adverse impact. So that's the third, will it stay or will it go?
Agent and Broker Oversight
[00:02:10] Stacey Richter: Fourth, and lastly, The whole agent broker realm. Additional CMS and government oversight over misleading or inaccurate information coming from the marketing or the agent broker marketing world.
How will that look in 2025 and moving forward? This last one, I'm kind of all over the nuance there after reading posts and comments by Samantha George, and I would recommend following her on LinkedIn would be my suggestion. I am reflecting back on the Ann Kempski episode where we talk about the whole, really consider the downstream impact when making any policy changes, because there can be unintended consequences.
Current Issues and Industry Challenges
[00:02:51] Stacey Richter: Now, in a show about carriers, in this case Medicare Advantage carriers, I'd be pretty tone deaf not to mention the nation's ire at carriers at this exact moment in time, some of it extremely well earned and some of it reflective of an extremely dysfunctional healthcare system.
I'd also be tone deaf not to mention the MedPAC report. The Medicare Payment Advisory Commission report, which states that Medicare Advantage plans receive payments from CMS that are 122% of spending for similar beneficiaries in traditional Medicare. This translates to an estimated $83 billion in higher spending in 2024.
And I would lastly be remiss not to mention how Medicare Advantage plans are most carriers most profitable service lines with average earnings of around $1,800 per enrollee.
All of what I said is not some kind of grand revelation, of course, to most listeners of this show. And it's also not the topic of the conversation today. Although some of this did get asked and answered in the earlier shows with Betsy Seals. Again, links in the show notes.
One thing I will remind everyone about is that there are regional carriers that are not the big five who may or may not be doing big five types of things. And also, it is actually really difficult to run a Medicare Advantage plan successfully. They call it risk for a reason.
Betsy Seals' Advice for Medicare Advantage Plans
[00:04:17] Stacey Richter: One thing I really appreciated about the conversation with Betsy Seals that follows is her advice to contemplate value to the patient and make sure that anybody working on the carrier side, you have enough of a bead on what's actually happening to be able to identify when things are going off the rails, which does not seem to be the case in some instances.
This also, by the way, having a bead on what's actually happening on the ground, helps to ensure compliance and that's piece of advice two.
Last piece of advice is to learn how to be proactive and not reactive. And this is eminently more possible vis a vis data that's available and learning how to use it well.
Betsy Seals, my guest today, has had a very busy last couple of years since she was on Relentless Health Value the last time. Betsy is CEO and co-founder of Rebellis Group, a managed care consulting firm focused specifically in Medicare Advantage.
Rebellis was actually acquired in February of 2024 and joined as a family of a couple of other consulting firms that now Betsy heads up. So in short, she's really busy.
My name is Stacey Richter. This podcast is sponsored by Aventria Health Group.
Betsy Seals, welcome to Relentless Health Value.
[00:05:31] Betsy Seals: Thank you, Stacey. Very happy to be here.
[00:05:33] Stacey Richter: Let's dig into the show today, which is called “Will It Stay or Will It Go Now?” So as we're talking about Medicare Advantage trends, if we're thinking about will it stay or will it go, Star ratings and Star measures and what's going on there.
[00:05:46] Betsy Seals: Sure. So the Star ratings program applies to Medicare Advantage specifically, and it's really intended to be an indication of plan quality as dozens of different measures.
Both the weighting and what is being measured changes year over year, but fundamentally it was developed and is intended to be an indication of quality of the plan. And health plans receive bonus payments depending on how well they do with these Star’s measures.
[00:06:10] Stacey Richter: Because Medicare Advantage gets paid in kind of a capitated way. Per member, per month. The idea there is there is a perverse incentive to basically deny care, right? You kind of need some kind of measure of quality to counteract what potentially could be financial incentives to not serve members. That's how the Stars started.
[00:06:30] Betsy Seals: I would agree with that. I think we never want to create any environment where we're incentivizing either denying care or creating barriers to care.
So, a lot of the Star ratings measures are around access to care. Are around reducing hospital admissions or repeat admissions, obtaining routine screenings, exams. So, so yes, I would agree with that.
[00:06:53] Stacey Richter: All right. There have also been lots of lawsuits around these Star ratings lately. So maybe we Start there as we tee up what your future thoughts are here.
[00:07:03] Betsy Seals: There certainly have been. One of the things that we've seen recently is health plans, a number of health plans pushing back against their Star ratings and the calculation of their Star ratings. And there's a number of different pieces that have been pushed back on CMS around the structure of the program, the way that these measures are being calculated, vendors that are being used by CMS as delegates in performing secret shopper calls as an example.
And a lot of this has transpired just in 2024. So the interesting piece of this is that a number of these lawsuits have been won. So kind of fundamentally calls into question the quality of the program, the quality of the measures, and how that's being structured, as well as the transparency of data, which I think was a big piece of those lawsuits.
[00:07:50] Stacey Richter: In effect, what these lawsuits said, the Star ratings, the point of these Star ratings was supposed to be they are indicative of the quality of the plan. Like, that's the whole point of these Star ratings, and the lawsuits basically said the way that those measures were being rolled out and implemented, not transparent, number one, but number two, not really indicative. Like, we have a quality plan over here, and the way that you're measuring this doesn't measure actual quality.
[00:08:18] Betsy Seals: That was absolutely called into question. Yes, both the process for CMS kind of codifying the new measures as well as is this measure actually indicative of plan quality. So, a great example is a secret shopper call indicative of actual beneficiary experience. That was one of the questions on the line.
This is the first time we've seen such volume of organizations pushing back against CMS policy or method. This is new territory, I would say, for the industry, and especially considering the outcome. So then now we're at the end of the year with all these lawsuits being settled and largely won by Medicare Advantage plans, and we have a new administration coming in.
What will the new administration's method be for Star’s measures? Will there be changes to these fundamental underlying structure or items being measured or method of measurement? My perspective is yes, there likely will be. And it could have been that that would have happened anyways, you know, with the environment that we're in and the lawsuits having been won.
But especially with a new administration coming in, I think that a fresh look will be taken of the Stars program as a whole. And considering everything that's transpired this last year, I would say certainly Stars is going to stay. There's no question about that. But I do believe that we will see a different form moving forward than we have seen.
[00:09:34] Stacey Richter: And you're saying that because the new administration is potentially a little bit more friendly to some of these big companies?
[00:09:43] Betsy Seals: I would say in general, very, very 10,000 view level. Yes, I would agree with that statement, but also because what has happened with these lawsuits and all of the questions that have been brought into the light around the Stars program that we will likely see a re-look at the program to ensure that it's a reflection of health plan quality.
To ensure that it's a reflection of beneficiary experience, right? That's really important. And also ensure when we look at the program as a whole, health plans that are achieving quality receive bonus payments. Those bonus payments down the line end up in better benefits for the beneficiary. So with the goal of actually ensuring that the beneficiaries receive excellent care and robust benefits, it is important for us all to ensure that the Stars program is a reflection of quality and that the quality health plans are receiving those bonus payments which turn into benefits for the Medicare beneficiary.
So that, that's a really critical point. I think that we don't want to forget in all of this is that we're all responsible for doing what's best for the Medicare beneficiary in policy and in process.
[00:10:48] Stacey Richter: And so one of the things that you said definitely struck me, which is that it's hard for a Medicare Advantage plan to not only just thrive, but survive.
[00:10:58] Betsy Seals: We have seen big five carriers reduce market footprint recently. We have also seen some of the regional carriers, especially some of the regional Blues have announced their market exit completely from Medicare Advantage.
[00:11:11] Stacey Richter: Which seems to run counter to a lot of the charts and graphs that have been put out by KFF and others, which show the most profitable service line for a lot of these carriers is in fact Medicare Advantage. So how do you square those two things?
[00:11:25] Betsy Seals: Yeah, the most profitable line of business for any carrier should be Medicare Advantage because of reimbursement rates. However, we know that that's not always the case. And there are a hundred or probably, you know, a thousand different reasons that things can go sideways for those health plans, either in a service area or for a small regional health plan as a whole.
It is a difficult program. There are thousands of regulations. And thousands of strategies that can either mean success or not success in Medicare Advantage, so.
[00:11:55] Stacey Richter: And we did talk about the last time that you were on the show. Okay, so second trend to dig into here is the risk adjustment and recouping improper payments. What's going on there?
[00:12:06] Betsy Seals: Over, the past several years, we have seen a real focus on upcoding, certainly, and risk adjustment. We've seen the OIG audits that have come down where they have identified a lot of, what they've identified is improper payments, right, that needed to be recouped by the federal government.
And just as a trend ongoing from CMS and OIG, we see a focus on recoupment of improper payments. Now, of course, that's absolutely what they should be doing. If Medicare Advantage organizations have received payments that are inaccurate for any reason, they should be returned to the federal government.
But we have seen an increase in activity and method in terms of oversight of this function. So I think the question is, will that continue and will it continue as it is now or will it increase with the incoming administration? Our perspective, I would say, and my perspective is that we will not see it go away.
We've had a light shone on some pretty egregious practices, certainly. The federal government is now aware of how pervasive some of these issues are, and that we should expect to see that oversight method continue. Continue, I would say, not just for this administration, but in the ongoing future forever.
[00:13:17] Stacey Richter: Yeah, I think one of the things that you said really hit home for me, which is the pervasiveness of some of this stuff and just how deeply embedded some of these things, it appears, have really become, where there's just such an incentive to both upcode, the dummy code thing. There's just so many things going on.
The, you know, use some leg vascularization machine, use it in a wellness visit so everybody gets diagnosed with something. It just, there just seems to be so much in this area that it would almost be, that actually harms patients. Like if we're all, if we're all talking about the making sure that Medicare Advantage patients are best served, I mean, this not only is a financial issue, but when you have patients that are getting unnecessary, invasive stuff, like that just, it just feels really wrong.
[00:14:07] Betsy Seals: An interesting dynamic here. I've seen it over and over again, and this points the difficulty to really thrive in Medicare Advantage is that somebody within an organization comes up with a bright idea, which turns out not to be so bright, and compliance doesn't necessarily have view or catch that because they're very different parts of the organization.
A lot of the risk adjustment activity can be around AI or machine learning algorithms. A lot of compliance organizations within MA plans are not as technologically savvy in terms of their oversight. So that's a real imbalance that we see and risk adjustment because it doesn't directly impact beneficiary access to care, it doesn't directly impact beneficiary access to guaranteed rights such as grievances and appeals.
It often sits more in finance. So that is a mismatch that we have that we really, as an industry, need to cure in terms of the compliance, sophistication, and oversight of risk adjustment programs.
[00:15:01] Stacey Richter: But it also has to do with short term versus long term thinking as well. Like someone comes up with a bright idea that's going to really help this quarter, the organization has to be sophisticated enough and have the risk tolerance and mitigation in place to say like, no, we're not going to do that.
[00:15:20] Betsy Seals: Yes, absolutely. And now that we have seen all the increased oversight and outcome of that oversight, it's a real risk. Whereas I think there was a time period where it wasn't a real risk. And so some organizations were taking a higher level of risk tolerance when it comes to risk adjustment, again, because it doesn't, it directly impact beneficiaries access to care or care being provided.
And now CMS OIG has really brought the hammer down, which is healthy, you know, the hammer needed to be brought down on those practices and a light needed to be shown on those pieces of risk adjustment so that we can then address them as an industry, before government oversight has to come in and do it for us. I think that's the important part, right? We're responsible for compliance and oversight of the organization. It shouldn't have to come from CMS or OIG.
[00:16:06] Stacey Richter: Theoretically, that would be good.
[00:16:08] Betsy Seals: There are dozens, hundreds of health plans out there that have not participated in non-compliant risk adjustment practices. That's important to see as well.
[00:16:16] Stacey Richter: Watch this smooth segue. I'm gonna tee up our next topic right now, which is AI and just the regulation of AI and all the different ways that can go right or horribly wrong, really. You can definitely see how some of these, let's just say, untoward use cases come to be because this is also new stuff.
So if you have a legal team or a risk mitigation team, who's really not lockstep with some of these technological advancements, again, something can seem very, very great in theory and then wind up going horribly wrong in practice. But, if you were going to sum up our number three trends that we're keeping an eye on here, AI.
[00:16:56] Betsy Seals: This one is very different than risk adjustment, where it absolutely does have direct impact on beneficiary, not only access to care, but truthfully, lives, right? And, and I'm not exaggerating when I say that. It has a, an impact on beneficiary lives. So this is extremely important for the industry to take note of.
We have seen a couple, more than a couple, really egregious uses of AI. And I very much doubt that the intent for anybody in that organization was to have the outcome that was ultimately there. It was likely a matter of not understanding or not fully vetting the way that that algorithm was being used or that, you know, AI is being used as a larger general statement. And also, I will say in our experience, A lack of sophistication from a lot of compliance organizations to understand and oversee AI and how that's being used. So, now we know, right?
We know how dangerous it can be. And we do expect there to be additional regulations that will come down around the use of AI and oversight requirements around AI. We've already started to see that process. But really, the compliance areas, the compliance officer within MA plans must have an understanding of how AI is being used within the organization, and especially when it comes to access to care or making any type of prior authorization decisions.
[00:18:15] Stacey Richter: You know, risk adjustment. The plan is going to make more money. You know, like if they're upcoding or dummy coding or whatever, there could be financial implications, I guess, depending on what the patient's out of pocket is, which shouldn't be underestimated, but that is more of a financial machination than a clinical machination.
If we're talking about, though, the use of artificial intelligence to determine, like, for example: How many days a patient is approved to stay in a skilled nursing facility, or again, whether we're going to deny care. These are clinical decisions. You listen to the patient stories. Like you have a patient with cancer, you have a very, very sick person who has a very short window in which something needs to happen.
And there a lot of times isn't just even the time or the energy or to run through some egregious, worst case, I guess, appeal process. Which may or may not be easy, seamless, understood, taken advantage of. There was this one case where a AI algorithm was purchased, used, it was meant to be an augmentation, not a replacement for humans looking at things or clinicians looking at things.
And instead it was like, hey, we're gonna save money. We're gonna take all the humans out of the equation. There was a number of alarm bells that were raised by people who were using these things. It was like mutiny on the bounty. All the clinicians were like, you can't keep doing this. And yet it, it continued. Which, yeah, the, thus the lawsuit.
[00:19:39] Betsy Seals: It's terribly, terribly sad in those, you know, examples that we see. And I will say, even though, yes, there are regulations and processes in place where these things can be appealed in an expedited manner, the number of Medicare beneficiaries who even understand that or could go through that process, especially as a cancer patient or any other type of a similar, condition, there's no way.
And we know data tells us that it just doesn't happen. And so that beneficiary does not receive the care more times than not. And we know the outcome of that. I would say within the past about three years, so after maybe last time we talked, um, I had a family member on Medicare and I would say my eyes were opened.
I've been in Medicare Advantage for 20 plus years, so I know the program in and out. But for this person approaching the program and all of the red tape, regulation, whatever we want to call it, knowing who to call, how to ask for what they wanted, virtually impossible.
And this is a, you know, very intelligent college educated professional. The average Medicare beneficiary will just not be able to go through the process to get the care needed. And that's what we have to keep in mind. We are responsible for lives and how we're making these determinations.
[00:20:50] Stacey Richter: Like let's just put it this way, payers are not necessarily known for their agility and their nimble, pretty much anything. But if we're rolling out a brand new technology that could have horrible downstream impact, we kind of have to be agile and nimble because it basically has to be something where you're doing a series of you try something, you look at the impact.
If that impact is negative, you have to, in the moment, be able to adjust. Otherwise, it gets really risky that you try something and you say you're going to do it for the next year or whatever. It's having terrible impact and no one's going to fix it immediately. So, using some of these technologies definitely feels to me like it requires a really thoughtful look at what processes are and how things are evaluated and to be next right considered action about it, which is, again, it's that is very different and difficult, I think, for some of these larger, don't change fast kinds of organizations.
[00:21:50] Betsy Seals: A hundred percent agree. It has to be real time oversight and especially with a focus on anything that's being denied or delayed. Really have to look at those decisions critically.
[00:21:59] Stacey Richter: Lastly, number four on our list, we have the agent/broker compensation and override payments, which is a, as we talked about this also at length in 2022. So this is not new, but what's going on now?
[00:22:12] Betsy Seals: Yeah. So it's been really interesting and you know, we've seen, this has always been an area of focus going back to CMS implementing the Fair Market Value Commission structure in 2008. So this has been a subject of conversation and area of focus for many, many years.
And all of that focus has been around a not incentivizing agents and brokers to enroll one beneficiary over the other for any monetary reason. The choice should be around what's best for that beneficiary. Of course that should be what the choice is around.
So the proposed regulation that we saw was that the override payments, so in addition to that fair market value payment that goes to the agent or broker, that the payment that goes to the upline, that there are regulations put in place to monitor and oversee and limit that payment. Because what we have found, and I have seen this since 2008, since this fair market value was implemented, is that there's kind of this loophole where in many cases additional payments are being made but they're called overrides and they're being paid to the upline.
That was the purpose of this proposed new regulation and ultimately did not go through for AEP 2024 for 1/1/2025 enrollments. And I think the question is, will we see another iteration of that? Will that be implemented? What will it look like? Is that even the right way to look at this issue and how to regulate what's going on in the industry?
My personal perspective, if I had a crystal ball, is that we will not see an exact replica of what we saw before, of proposed or implemented. I think it was a, little bit too much too soon in terms of change kind of would have fundamentally changed the whole structure. But that we do as an industry need to focus on what these override payments are being paid for, who they're ending up going to, and ensuring that that structure does not impact, you know, the agent recommendations to that beneficiary. That's the ultimate piece that with CMS's intent that we need to ensure is intact is that integrity of the process.
[00:24:16] Stacey Richter: What I'm understanding here is there are some bad apples as there always are, right? Like you say agents and brokers and there's going to be whatever small percentage that are definitely putting profits over patients like that is going to be a thing.
However, there are agents and brokers who are trying really, really hard to get the right members into the right programs. So I think, you know, this is always the balance that winds up happening. Like you're trying to figure out how to curb the behavior of some of these bad apples.
But if you're trying to do it in such a way that causes people who are actually doing the right thing, to not be able to do their jobs well, then you wind up actually with a net negative to a certain extent so like that's always a dynamic.
[00:25:01] Betsy Seals: Yeah. Or you've made it impossible for them to make a living at doing the great job that they're doing so they're going to have to go do something else. So yeah, you're absolutely right. You know, the majority of agents and brokers across the nation are providing a very valuable and needed service.
Enrolling in Medicare Advantage plan, understanding how the benefits work, determining if you whether should change each AEP, is no small fall feat and there are so many different pieces that go into that in terms of, benefit structure and provider network and everything else.
So the role of agent and broker is very important to the Medicare beneficiary and them ultimately, receiving the benefits in the plan that they need. And so, yeah, we don't want to throw out the baby with the bathwater, right? We want to make sure that whatever we put in place is not limiting the good work that most agents and brokers are doing in the industry, but is ensuring that bad apples are weeded out through the process.
[00:25:52] Stacey Richter: And your prediction moving forward here is that there still will be eyes on, but probably not, as you said, an exact replica of what was proposed in the past.
[00:26:01] Betsy Seals: Yes, that is what I predict moving into the, to the coming years and certainly continued focus on the misleading commercials and different things we've seen in the industry. And then a different iteration of, of the rules around override payments.
[00:26:15] Stacey Richter: You know, one thing I did want to ask you, so that that was our list. Today we talked about, we've talked about STARS and what might be going on there. We talked about risk adjustment. We talked about the use of AI. We talked about agents and brokers.
I know one thing that's also on people's minds is kind of this balance of power between provider organizations like big health systems and Medicare Advantage plans. And one of the things that we saw a lot in 2024 was hospital systems and even just independent providers who are like, I can't work with Medicare Advantage.
Like they're just, they're lowering my rates to such an extent that like, we're out. Do you have any thoughts on what's going to happen there?
[00:26:50] Betsy Seals: Yeah, there is, there is a push and pull certainly between large provider, you know, or health systems and Medicare Advantage plans. And there's also, in the reverse, right, a lot of emphasis on provider network adequacy from the health plan perspective.
So this partnership is critical to MA health plans staying alive in the industry because you have to meet adequacy standards and we've seen a lot, no, we'll talk about that next time, maybe a lot around that. And then, obviously, health systems have to make money. So, we really encourage coming to the table as partners, understanding that both organizations want to serve the beneficiary, want to stay in industry with a contract.
But how do we get there? It's a difficult negotiation, and unfortunately, we have seen some health systems leave networks, and ultimately, that impacts that Medicare beneficiary. So, with that in mind, how do we come to the table with those negotiations and move forward?
[00:27:42] Stacey Richter: Yeah, and that's something that I have talked about several times and in a bunch of different shows just what is collaborative EQ or IQ.
And that will be a skill moving forward because of just the absolute necessity. There are just simply multiple entities that are involved in any given patient journey. There always is a payer. There always has to be clinicians and doctors and a team that surrounds that patient to actually provide the care.
So being able to work together is just becoming more and more of a vital skill set. And sadly, it's not been emphasized, maybe, or appreciated, I think, to a certain extent in the past. There's just been these silos
[00:28:27] Betsy Seals: I agree with you. And of course, people are people, right? Not always going to be collaborative, unfortunately. And I think that that's something that, you know, that's a larger comment, of course. But when it comes to. The healthcare industry and our ultimate goal, you know, I started my career in Medicare Advantage in customer service for a scan health plan answering phones for a number of years while I was finishing my degree.
So I think I have a unique perspective on the impact of the Medicare beneficiary and also the day to day life and struggle of a Medicare beneficiary because of that experience where many executives in on the payer side and even on the health system side do not.
It's really important to remember that people that we are serving, the vulnerable population that we are serving, and that we are in this career in healthcare, in all aspects of healthcare, we are taking on a responsibility for that vulnerable population. And I think that's forgotten a lot of times, which is unfortunate.
[00:29:24] Stacey Richter: The other thing that I pointed this out, I think in the show at the end of November, that at the end of the day, what is becoming more and more possible to evaluate is what value is accrued to the patient?
With all the data sets that are happening right now, all the data that's, that is freely flying around, I don't think we can forget that everything we're doing is supposed to add up to value accrued by the patient, for the patient, at the patient level. And if that value is never going to occur to the patient unless three people work together, then it actually becomes a business critical skill to be able to work together. So that's what I think.
[00:30:06] Betsy Seals: Yeah, I would agree. And I think there's a hundred different examples that we can point to around what we're doing in healthcare and does it or does it not actually have a value or a benefit to the beneficiary. And I think that when we're looking at. All of the different aspects of healthcare, it's important to have that question in mind.
Even coming down to, you know, the supplemental benefits packages that we're putting together. Are we putting those together because we want to compete with this other health plan and because we think the agents can sell them? How are they being implemented to actually impact the beneficiary's health journey?
That's important. What data are we looking at to say that this is the right supplemental benefit for the population of our health plan? All of those pieces are critical for kind of how we move forward in, in providing healthcare for this population.
[00:30:52] Stacey Richter: So I was going to ask you for a couple of pieces of advice for anybody working for, about, along with Medicare Advantage plans, but I'm going to, I'm going to slide in our first piece of advice because I think you just said that really clearly to anytime we're making business decisions or strategic decisions, something that should be considered right up in the front is how does this contribute to value to the patient?
Does this contribute to value to the patient? That should definitely be part of a, this should certainly be a strategic imperative that gets considered every single time that we're making some of these decisions, large or small.
[00:31:28] Betsy Seals: Yes. I would absolutely agree. And in our experience, one of the ways to achieve that, and you gave the example earlier, the clinicians were sounding the alarm and nobody was listening, right?
Or nobody, we'll say nobody was listening. And so when you're looking at benefit structure, as an example, having your clinicians there, having your pharmacists there, it's not just a discussion for the product team or the sales and marketing team. It's those clinicians and the pharmacists who understand how it's going to impact the beneficiary.
Looking at data to inform decisions, right? All of that's really important. So ensuring that all of the right voices are at the table to be heard is one of the fundamental pieces for that.
[00:32:03] Stacey Richter: Point number one is consider the value, make sure you've got the right stakeholders at the table to consider the value that is going to wind up accruing or not to the patient, like the member. That is absolutely vital piece of advice here. Do you have any additional kind of thoughts that you might want to offer?
[00:32:19] Betsy Seals: Yeah, I would say a couple of different pieces and these are kind of zooming out a little bit for compliance organizations within MA health plans to understand some of the key risks when it comes to technology and use of technology.
And to get in front of those with their own algorithms, right? Compliance oversight programs can have algorithms as well. So how are we going to catch these things before CMS does or before there's a, an adverse impact on a beneficiary? So that would be a big piece of, I would say, our perspective or advice on how to move forward in our current environment is getting more technologically savvy in our compliance oversight programs.
The other piece I would say when it comes to Stars, a lot of organizations are surprised when they receive their Star ratings. Nobody ever needs to be surprised, right? There are programs and technology to track how we're performing in Stars to close gaps near the end of the year for measures that are highly weighted or have beneficiary impact.
So that's another big picture piece of advice that I would say moving into this year because we've seen so much activity in Stars is to really get in front of your strategic program for Stars.
[00:33:27] Stacey Richter: So the second thing that you had mentioned and behind our what's the value, show me the value for the patient or the member is compliance organizations to really understand what they're dealing with from a technological and also data perspective.
Like I was just listening to someone from the Joint Commission talking about how some organizations are just trying to get these huge data lakes. Because they think that they're commercially viable, but at the same time, you get a huge data lake, you can now re identify HIPAA data. Like, there's all these different things which can very easily happen if somebody's not careful.
So if you have a compliance organization who's like, Sure, I don't see anything wrong with that, but not understanding kind of these larger implications, you can get yourself in a world of trouble. So that's your second thing. And then the thirdly that you said is that these days, there's no reason to be surprised.
Surprises are bad all around because just five alarm fires and now it's reactively, what are we trying to do to fix this? Whereas if we would have figured it out Q3, then there would have been ample time to try to redress stuff. So there's all kinds of issues with surprise. And as you're saying, there are resources, etc, out there so that no one should be surprised at this juncture. So point of advice number three is figure out how to be proactive, not reactive.
[00:34:41] Betsy Seals: Absolutely. Use data to your advantage. Use predictive analytics to your advantage. Use, you know, organizations in the industry who are focusing on strategic initiatives and tracking around Stars as a great example to your advantage.
If you've been surprised before, we don't have to be there again. And that comment really would expand beyond Stars, but since we discussed Stars today.
Conclusion and Final Thoughts
[00:35:00] Stacey Richter: Betsy Seals, if someone is interested in learning more about anything that we talked about today, where would you direct them for more info?
[00:35:07] Betsy Seals: You can go to our website, rebellisgroup.com, for more information on Rebellis Group and the work that we do in Medicare Advantage.
[00:35:13] Stacey Richter: Betsy Seals, thank you so much for being on Relentless Health Value today.
[00:35:16] Betsy Seals: Thank you for having me.
[00:35:18] Dr. Vivian Ho: Hi, I'm Dr. Vivian Ho, I'm a health economist at Rice University and Baylor College of Medicine. I listen to Relentless Health Value religiously because this is the show for those who are part of the tribe that wants to improve the quality of healthcare, improve access to care and make it affordable. So make sure that you subscribe to the newsletter and subscribe to the podcast and keep up with every episode.