For this client, Lumeris developed contracts between the payer and providers in the network that include incentives tied to improved quality and the resulting financial outcomes. This required the aggregation and rationalization of data from disparate sources across the care continuum. The services, supported by the ADSP’s tools, information, and reporting, enabled better, value-based decisions.
Client Profile
- Medicare Advantage Prescription Drug Plan
- More than 40,000 members
- 346 PCPs and 2,729 specialists
Specific Solutions
- Established Collaborative Payer® Model
- Aligned incentive contracts between payers and providers
- Modeled MAPD benefit design on HMO narrow network of accountable PCPs and specialists, prior authorizations, referral process, $0 premiums, extras
- Provided a mentorship program to align physician behaviors around accountability to achieve the Triple Aim +1™
- Established a system of collaborative medical management
- Provided consulting to help medical professionals understand opportunities for improvement
- Enabled providers to perform proactive assessments on high-risk patients
Outcomes:
Cost
- ~65% MCR (2013 before distribution of physician quality-based compensation)
- 30% reduction in costs and 40% reduction in readmission rate compared to FFS Medicare
Quality
- 4.5 Star MA Plan for 3 years in a row
Patient Satisfaction
- Overall rating of health plan consistently above national average in CAHPS surveys
- Largest market share for 3 years
- Over 97% patients seen annually
Physician Satisfaction
- Over 80% of providers consistently rate that they are satisfied with their collaborative payer partner
* Percentages based on comparing 2012 actual Lumeris client results to unmanaged population data obtained from CMS.
