The rationale for the elements stated within the mission, vision and values statement is that through educating and assisting patients in signing up for and choosing their provider under the Medicare Advantage plan that the patients will be enabled to receive the best possible benefits for their individual health maintenance needs.
E. PROPOSED STRATEGIC GOALS
Strategic goals of this program includes those as follows:
1) Enrollment of all patients in the Medicare Advantage program who are eligible for this coverage.
2) Assisting all Medicare Advantage enrolled patients in utilizing this coverage to the best possible level enabling them to receive the best care possible.
F. IDENTIFICATION of CRITICAL SUCCESS FACTORS
Critical success factors are identified as being those as follows:
Adoption of the necessary technology applications to assist patients;
Efficiency and effectiveness in getting information out of patients concerning the assistance offered by the HMO; and Response level of patients to the information provided by the HMO.
G. METHOD of MEASURE to ASSESS GOAL ACHIEVEMENT
The method of measure that may be used in assessing the achievement of these goals is the level of enrollment in the Medicare Advantage Program by those patients who are eligible for this program. Furthermore, the HOS program, which accesses the overall health of patients, will be used to identify the health outcomes associated with achievement of this goal.
H. PROPOSE STRATEGIES and RATIONALE
Strategic goals proposed in this work include those as follows:
II. STRATEGIC IMPLEMENTATION
In order for Health Maintenance Organizations to actually 'do' what the title makes claim to, then that organization has to critically analyze the strategy that is being utilized in reach the goals that have been stated. In this case those goals include very systemic processes because the evaluation in this initiative it is the system processes that will determine success or failure. In other words, it is a system marked by sure approval based upon one factor of determination and that being whether the individual applying already receives Medicare? If yes, the individual is automatically approved. The catch in this very easy and systemic process are the array of choices, which must be understood.
According to the work of Rosenfield, Bernasek and Mendelson entitled: "Medicare's Next Voyage: Encouraging Physicians to Adopt Health Information Technology": "Although there is growing consensus that health information technology (HIT) will be critical to improving health care quality and reducing costs, physicians' investments in technology remain limited. As the largest single U.S. purchaser of health care services, Medicare has the power to promote physician adoption of HIT. The Centers for Medicare and Medicaid Services should clarify its technology objectives, engage the physician community, shape the development of standards and technology certification criteria, and adopt concrete payment systems to promote adoption of meaningful technology that furthers the interests of Medicare beneficiaries." (2005) Technology hardware and software needed to implement this strategy in the Healthcare Maintenance Organization must be purchased and employees that will be consulting with eligible patients must be trained for using the necessary technology in assisting these patients with their application for this plan. This is actually a very simple process in which the individual goes online via the Internet to the designated Social Security Administration website and applies for this plan by filling out an eligibility requirement questionnaire. As simple as this process actually sounds and generally is for those who will be in charge of doing this to benefit a patient, simultaneously it presents a barrier for many individuals who do not have a computer and for those who do the barrier is presented when they do not have access to the Internet. Once the patient has applied for eligibility of this program Medicare sends out a confirmation package to the individual. Rarely does the individual have to return to the website however; in the case that this is required, a second appointment to consult with the individual assigned to these cases will be arranged.
Training and Education for Strategic Intake of Patients
Individuals who perform the intake applications of patients must be specialized in Medicare benefit coverage therefore special training will be required in complying with Medicare and Social Security Standards for making these type of applications for individuals who are in receipt of these benefits specifically to prevent conflict of interests in assisting patients.
Medicare Preferred Implementation and Requirements of HMOs
The training of the aforementioned individuals will serve two-fold in that it automatically have the patient enrolled for coverage that benefits the patient the most in terms of payment thereby bringing about a reduction in the out-of-pocket costs of the patient and results in a better chance of healthy lifestyle for the patient.
Process of Enrollment
The point-of-contact from the HMO must contact the patient proactively if the HMO will meet the no penalty deadlines of Medicare.
Strategic implementation of this plan relating to providing assistance to patients of the HMO in applying for 'Part D' of the Medicare plan will begin with contacting the patient and setting up an appointment for the patient to come into the HMO office and consult with the individual assigned to case management of the patient's cases who qualify and are eligible for this plan which includes all recipients of Medicare. The patients should be advised that they will need to bring their Medicare and Social Security cards with them to this appointment as well as proof of income and other information relating to their monthly expenses and other assistance they receive from other than Social Security Income benefits. The patient should be instructed that upon receipt of their enrollment package that they should telephone the HMO and make an appointment for review of the confirmation material that they receive from Medicare concerning enrollment in the "Part D" program. At this time the representative of the HMO who is assisting patients with enrollment in the Medicare "Part D" program should assist the patient in reviewing the plans that are available and in making a choice of the plan that is most suited for the patient. This can be accomplished by submission of bids to participating providers of coverage in the region the patient is located. Upon receipt of bid the HMO would review the possible options with the patient that may be chosen from. The patient's choice would be then input to the Medicare program with the patient present during the process. Requirements of Medicare for assisting patient are met in this process. The patient benefits financially and in terms of the best possible coverage.
III. STRATEGIC CONTROL
As related in the work of Jones, Jones and Miller the Medicare Health Outcomes Survey was developed in 1996 by the Centers for Medicare & Medicaid Services (CMS) in an initiative to measure the quality of life and function health status of Medicare beneficiaries enrolled in managed care. The Medicare Health Outcomes Survey (HOS) is a program that gathers valid and reliable health data for those who are in Medicare managed care and used in quality improvement, public reporting, plan accountability and improvement of health outcomes based on competition. (Jones, Jones and Miller, 2004; paraphrased) Jones, Jones and Miller state that the context for the development of the HOS was "on the convergence of the following factors:
1) a recognized need to monitor the performance of managed care plans;
2) Technical expertise and advancement in the areas of quality measurement and health outcomes assessment;
3) the existence of a tested functional health status assessment tool (SF-36) I, which was valid for an elderly population;
5) CMS leadership, and 5) political interest in quality improvement." (2004)
It is reported that since 1998 "there have been six baseline surveys and four follow up surveys. CMS conducts the following with its partners and performs the following task as a part of the HOS program:
1) Supports the technical/scientific; development of the HOS measure, 2) Certifies survey vendors, 3) Collects Health Plan Employer Data and Information Set (HEDIS®)2 HOS data, 4) Cleans, scores, and disseminates annual rounds of HOS data, public use files and reports to CMS, Quality Improvement Organizations (QIOs), Medicare+Choice Organizations (M+COs), and other stakeholders, 5) Trains M+COs and QIOs in the use of functional status measures and best practices for improving care, 6) Provides technical assistance to CMS, QIOs, M+COs and other data users, and 7) Conducts analyses using HOS data to support CMS and HHS priorities." (Jones, Jones, and Miller, 2004)
According to Jones, Jones and Miller: "During the time of HOS development, there was an increased interest in measuring outcomes of health care. The use of outcome measures in quality improvement efforts stems, in part, from a desire to focus on the impact of care on patients." (2004) it is noted that it was asserted in the work of Berwick (2004) that the patient's experience should be "the ultimate source of defining quality." (Jones, Jones, and Miller, 2004) Jones, Jones and Miller (2004)…