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THE CLIENT
The client for this project is a health plan that provides both traditional Medicare Advantage (MA) plans and those that address chronic conditions and social determinants of health, to reduce healthcare disparities among historically underserved populations in the central and eastern United States. Their plans integrate Medicare Part A and Part B benefits with Part D prescription drug coverage, along with providing robust extra benefits.
BACKGROUND
MA Plans are assuming bigger risk in their Part D benefit spending than in previous years due to recent changes in MA rules. Audits of the program, a requirement to participate in MA, will mean that there are increased compliance and operational risks in how plans go about serving their members with the Part D benefit. As the regulatory environment changes, guarantees in pharmacy benefit manager (PBM) contracts need solidifying, and will require rigorous oversight by the plans to reduce risk. MA plans need to ensure alignment and collaboration across their organizations and with vendors to optimize initiatives in quality and Stars. It is also important to establish alignment and engagement early within the yearly bid cycle. T he client engaged HMA due to our diverse expertise in Part D plans including operations, PBM and vendor oversight, health plan leadership, Stars and quality programs, financial and actuarial analysis, and compliance.
APPROACH
HMA performed an assessment to analyze and measure the effectiveness of Part D operations, including a comprehensive review of the plan’s Part D benefit, and identified gaps in Part D policies, procedures and staffing. The effort also documented operational efficiencies, quality improvement recommendations and opportunities for the client to increase their Part D Star ratings. HMA identified areas of improvement and provided actionable insights to guide future decisions. The assessment utilized a combination of data, documents and interviews to cover various dimensions such as performance, compliance, effective oversight, and collaboration.
RESULTS
The final report recommended a series of organizational changes and quality improvements to enable the client to optimize their Part D operations. Recommendations were made in the following areas:
- Policies and procedures: Identified gaps in the client’s internal policies and procedures, and provided recommendations to cure the deficiencies, including the development of desk-level guides.
- Comprehensive oversight: Identified oversight gaps in vendor management and provided recommendations to improve.
- Part D strategic leadership & proposed new staffing model: HMA drafted a best-in-class organization and staffing plan that permits the client to scale up with a delineated staffing structure designed to ensure optimal oversight of Part D quality.
- Collaboration: Identified gaps in PBM contracts and provided recommendations for negotiating and bolstering account management. The new plan also recommends expanding the Part D team’s role and involvement with provider engagement teams in order to increase overall CAHPS results to improve Star ratings.
- Financial/actuarial analysis: Identified changing regulatory reporting (Direct and Indirect Remuneration) and capturing required information related to Manufacturer Discount Program (MDP) and Medicare Prescription Payment Plan (M3P).
HOW HMA CAN HELP YOUR ORGANIZATION
If your organization wants to undertake a similar review of your Part D organization, we encourage you to engage with your teams to review and prioritize findings and recommendations to build out best practices and best in class plan operations. HMA can help you develop a plan and guide you through the processes, identify issues that might not otherwise be identified internally, and provide recommendations for ways to optimize your efforts. Our team brings together expertise in Medicare Advantage, Part D, pharmacy, quality and accreditation programs, on the ground leadership experience in health plans, financial and actuarial expertise, with in-depth insider knowledge from our work in states across the country. Contact us to learn more about how HMA can help.
THE CLIENT
The client for this project is a health plan that provides both traditional Medicare Advantage (MA) plans and those that address chronic conditions and social determinants of health, to reduce healthcare disparities among historically underserved populations in the central and eastern United States. Their plans integrate Medicare Part A and Part B benefits with Part D prescription drug coverage, along with providing robust extra benefits.
BACKGROUND
MA Plans are assuming bigger risk in their Part D benefit spending than in previous years due to recent changes in MA rules. Audits of the program, a requirement to participate in MA, will mean that there are increased compliance and operational risks in how plans go about serving their members with the Part D benefit. As the regulatory environment changes, guarantees in pharmacy benefit manager (PBM) contracts need solidifying, and will require rigorous oversight by the plans to reduce risk. MA plans need to ensure alignment and collaboration across their organizations and with vendors to optimize initiatives in quality and Stars. It is also important to establish alignment and engagement early within the yearly bid cycle. T he client engaged HMA due to our diverse expertise in Part D plans including operations, PBM and vendor oversight, health plan leadership, Stars and quality programs, financial and actuarial analysis, and compliance.
APPROACH
HMA performed an assessment to analyze and measure the effectiveness of Part D operations, including a comprehensive review of the plan’s Part D benefit, and identified gaps in Part D policies, procedures and staffing. The effort also documented operational efficiencies, quality improvement recommendations and opportunities for the client to increase their Part D Star ratings. HMA identified areas of improvement and provided actionable insights to guide future decisions. The assessment utilized a combination of data, documents and interviews to cover various dimensions such as performance, compliance, effective oversight, and collaboration.
RESULTS
The final report recommended a series of organizational changes and quality improvements to enable the client to optimize their Part D operations. Recommendations were made in the following areas:
- Policies and procedures: Identified gaps in the client’s internal policies and procedures, and provided recommendations to cure the deficiencies, including the development of desk-level guides.
- Comprehensive oversight: Identified oversight gaps in vendor management and provided recommendations to improve.
- Part D strategic leadership & proposed new staffing model: HMA drafted a best-in-class organization and staffing plan that permits the client to scale up with a delineated staffing structure designed to ensure optimal oversight of Part D quality.
- Collaboration: Identified gaps in PBM contracts and provided recommendations for negotiating and bolstering account management. The new plan also recommends expanding the Part D team’s role and involvement with provider engagement teams in order to increase overall CAHPS results to improve Star ratings.
- Financial/actuarial analysis: Identified changing regulatory reporting (Direct and Indirect Remuneration) and capturing required information related to Manufacturer Discount Program (MDP) and Medicare Prescription Payment Plan (M3P).
HOW HMA CAN HELP YOUR ORGANIZATION
If your organization wants to undertake a similar review of your Part D organization, we encourage you to engage with your teams to review and prioritize findings and recommendations to build out best practices and best in class plan operations. HMA can help you develop a plan and guide you through the processes, identify issues that might not otherwise be identified internally, and provide recommendations for ways to optimize your efforts. Our team brings together expertise in Medicare Advantage, Part D, pharmacy, quality and accreditation programs, on the ground leadership experience in health plans, financial and actuarial expertise, with in-depth insider knowledge from our work in states across the country. Contact us to learn more about how HMA can help.
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