Lumeris
Optimizing the Medicare Advantage/payer Space

The U.S. healthcare system is on an ever-increasing growth tangent, with healthcare spending projected to grow by an annual average rate of 5.4 percent between 2019 and 2028. Undermining this promising potential is the high rate of process inefficiencies and wastage generated annually. Such unsustainable growth is primarily influenced by the lack of care coordination, which has driven the need for value-based care (VBC) payments model in which physicians are incentivized to provide high-quality care to patients. Pioneering this shift is Centers for Medicare and Medicaid Services (CMS). Since its inception in 2010, as a part of the Affordable Care Act (ACA), CMS has launched over 50 pilot models for helping care delivery providers in their transition toward value-based care. However, only six of 50 models yielded statistically significant savings for Medicare and taxpayers, while just four out of the six met the requirements defined by the Center for Medicare and Medicaid Innovation (CMMI). To make this refreshed strategic direction a reality, it is incumbent that Medicare providers focus on addressing social inequities and their role in advancing the delivery and financing of healthcare in the U.S.

Helping healthcare organizations navigate through the ever-evolving healthcare landscape is Lumeris, a value-based care managed services operator for health systems. The company enables health systems to deliver exceptional value-based care successfully through its market-leading population health solution, the Population Health Services Organization (PHSO). “We are leveraging technology to optimize the Medicare Advantage/payer space. Our company is transforming the payer-provider-patient space and optimizing the contract management processes to operate with efficiency, align to value, and engage physicians to produce better patient outcomes,” states Richard Jones, Essence President and Board Member at Lumeris.

In conversation with CIO Applications, Jones and Jean-Claude Saghbini, the CTO at Lumeris, mention how the company is developed to help payers, health systems, and physicians achieve value-based care utilizing industry best practices.

What were the factors that led to the genesis of Lumeris?

Jones: Several years ago, Essence Healthcare, a Lumeris-operated Medicare Advantage plan, was the first stepping stone for making Lumeris what it is today. Our company offers a holistic and macro solution to manage outcomes for Medicare, Medicaid, commercial and individual populations. We developed the Lumeris model in 2007 to enable a new partnership by sharing data and creating processes around a collaborative payer-provider contract. We have created shared goals for both insurance companies and physicians to facilitate better outcomes, higher quality, more transparency, and interactive relationships with the patients. We have now scaled up from this single market approach to have achieved a five-star rating in terms of quality and outcomes for our Medicare Advantage plan.

In doing so, we have essentially executed a robust collaborative process of sharing information. Rather than having a dearth of information between payers and providers, our model can inform the visits and the interactions while improving costs and benefits with information enablement. Over 15 years, our footprint has expanded to multiple organizations across the country. Once our model took off, we started developing it further to align with multiple market needs. We have since been able to help several provider systems and physician groups to achieve positive outcomes. We continue to do the same based on acquiring the data in a timely manner, aggregating it into actionable information, and creating better patient outcomes.

Please elaborate on the solution you have in place.

Saghbini: What we put forth is a three-part solution the population health management playbook, services offering powered by technology, and a world-class technology stack.

Our population health management playbook, developed over the course of a decade, has been optimized with proven results. This technology-driven PHSO enables health systems to optimize clients’ move to value-based care, reduce costs through better patient outcomes driven by higher quality care, and strengthen their market advantage. It further improves their existing contracts to help expand into newer markets with higher-risk contracts and ultimately enhance member satisfaction. We also provide clients with the technology and the processes to help health systems move to value, strategically and efficiently.

On the services offerings side, our proven technology enables the implementation of our Lumeris model playbook. We work hand-in-hand with our clients to derive a mutually beneficial goal for them. Our technology-enabled collaborative payer operations benefit providers, members, payers while meeting the MAPD requirements. We empower the member-physician relationship so that it aligns providers with value-based care. Our company works toward continuous improvement, compliance, and integration of clinical and administrative functions for the payer. Our technology enables scalability and efficiency in the provider-payer relationship while providing aligned incentives, transparency, continuous innovation, and support to physicians and members in the delivery of VBC.

The last vital component of our solution is our world-class tech stack. Our cloud-based tech is purpose-built to manage population health and risk-based contracts, including Medicare Advantage. It allows us to operate data at scale. With advanced A.I. and data science capabilities, we can offer accurate predictions and classification of patients for developing optimal care pathways. We also offer a patient engagement platform, My Personal Care Platform (MyPCP), that enables patients to better manage their health from anywhere, anytime. MyPCP is a care orchestration engine that helps streamline the communications between patients and care providers to avoid provider redundancies and enable effective collaboration.

Jones: The provider/payer relationship is a two-way street. We build this ‘house’ on an equal amount of enablement. The intent was to create a health plan inside out that the clinician would feel equally included. We are thereby solving the industry problem from a member-oriented perspective where doctors become better at providing a higher quality of care with accurate population health data.

What are some of the unique aspects of Lumeris?

Saghbini: To enable an exceptional contract/provider relationship, technology enablement and the ability to extract enough pertinent data to execute it is vital. We use data not to run our business but to give providers the ability to run their businesses effectively. We leverage technology to empower providers so they can optimize their patient care and garner better outcomes. A big differentiator for us is our comprehensive, end-to-end solution, both in terms of the patient care journey and the offering we bring to the market in partnerships with our clients. The combination of the proven playbooks, services offerings, and the tech stack helps clients deal with different types of data extracted from various systems, including EHRs and claims data, to then deliver insights. We can take the insights and directly plug these into their workflows and ensure their effective adoption. Our strength is also proven by the fact that we have received high ratings in the CMS Star Ratings programs for multiple years, keeping us in the top percentile of M.A. plans in the country.

Jones: Added to what Jean-Claude mentioned, we have our own Medicare Advantage (M.A.) plan, Essence Healthcare, which is one of the premier M.A. plans in the country, averaging a 4.5-star rating over the past decade. CMS recently announced the new star ratings, and Essence Healthcare achieved the highest rating of 5 stars. Our PHSO offering is the technology that powers our M.A. plans, enabling us to better view the insights and processes that work and those that don’t. This provides us with the flexibility to quickly adjust and pivot as we continue to build on our playbook. At the same time, customers leverage the same deployed solution that we have successfully leveraged with the same advanced analytics and tools.

What do the future years look like for Lumeris?

Saghbini: From a technology standpoint, our key objective has always been to enable a higher quality of care at lower costs. To continue on this path, we will improve access to data sources and provide better insights for engaging providers and enabling better patient care. We are looking to include more non-clinical data and existing clinical ones to help view the progression of a patient through a path recovery or with a chronic condition. Another major expansion angle for us is investing in our patient-provider digital connectivity with our MyPCP solution to maintain the continuum of monitoring patients with remote data monitoring. Our goal is to create better connectivity between patients and providers through digital means, whether via text messaging, telehealth, emails, or phones. We believe that technology investments sit at the forefront of what we are doing to continue advancing to the True North Star for our company.

Jones: We are also looking to reach multiple populations and become more ubiquitous in improving patient outcomes and driving more visibility within the healthcare systems.