US Family Health Plan Cuts Readmission Rate for High-Risk Members to 11% By Upgrading Medical Management Programs

Challenge

Frequent regulatory and plan requirement changes, coupled with the need to adapt to pandemic challenges, prompted Uniformed Services Family Health Plan to find a partner to undertake a thorough review and restructuring of its medical management program. US Family Health Plan, a TRICARE Prime^® military health care option serving military families in New Jersey, New York, Pennsylvania and Connecticut for more than 30 years, wanted to keep its members as healthy as possible, paying special attention to those with chronic conditions, while also identifying and addressing any overutilization. In addition, it needed to update processes and technology to make it easier to stay in and report on compliance.

Solution

In 2020, US Family Health Plan brought in COPE Health Solutions to evaluate medical management leadership and core programs including utilization management (UM), care management (CM) and quality of care. The consulting firm measured and compared US Family Health Plan against national standards, benchmarks, best practices and Department of Defense requirements. Based on the analysis and recommendations, US Family Health Plan engaged COPE Health Solutions to implement a strategic rebuild of its medical management operation, provide interim leadership to run programs and recruit and train new leaders.

During the five-month rapid deployment, COPE Health Solutions:

• Created new processes and updated technology to strengthen such programs as disease management, complex care management and quality outreach, aligning with National Committee for Quality Assurance health plan accreditation.
• Incorporated social determinants of health (SDoH) and behavioral health into the programs.
• Bolstered and embedded data analytics and key performance indicators in the programs to enhance data-driven decision-making, tracking and outcomes reporting.
• Provided training for all staff on the new processes, technology and other changes.
• Helped recruit and train new leaders.

During the rebuild, COPE Health Solutions Senior Vice President Lesley Reeder, RN, MBA served as interim executive leader for quality, CM and UM while Principal Jerry Frank, MD stepped in as interim Chief Medical Officer for all clinical services and US Family Health Plan’s health centers.

“From the assessment through implementation and operation, COPE Health Solutions’ expertise has enabled us to transform our medical management operations and enhance the experience for our members and our providers. By building in best practices from processes to technology, we are in a much stronger position to improve member outcomes and health while managing utilization and costs,” said Jeff Bloom, Chief Executive Officer of US Family Health Plan.

Results

The improvements in medical management began delivering a substantially higher level of performance very early on. It has been maintained through the transition of leadership from COPE Health Solutions back to US Family Health Plan. As a result, the plan has been able to expand care for its members while leveling off costs. One tangible measure of success is a hospital readmission rate of 11% among members at high-risk for readmissions, mainly members 65 and older. That is significantly lower than the average 17% hospital readmission rate for Medicare Advantage programs.

It’s also improved provider experience. Focusing on a top hot-button issue for physicians, US Family Health Plan worked with the experts at COPE Health Solutions to begin streamlining prior authorization by making the process faster and easier with an online physician portal. It’s also reducing the number of services and procedures requiring prior authorization from more than 12,000 to 4,000.

Working with COPE Health Solutions, US Family Health Plan is building on this foundation. It is further adjusting its UM processes as it transitions to a new Third-Party Administrator for managing claims. Using data-based quality and other performance metrics and goals, US Family Health Plan continues to adapt and enhance medical management services and programs to meet the population’s care management needs as it strives to optimize operations and outcomes.

For more information, contact info@copehealthsolutions.com.