Overcoming the Top 5 Challenges Facing Medicare Advantage Plans

May 5, 2020 / BY KAREN IAPOCE, RN, MSN, Government Solutions Senior Analyst – ZeOmega

Medicare Advantage plans are extremely popular among seniors, creating new opportunities – and new challenges – for health plan administrators.

Over the past decade, enrollment in Medicare Advantage (MA) plans has exploded, nearly doubling to reach more than 20 million beneficiaries in 2018. By 2028, the Kaiser Family Foundation predicts that more than 42 percent of seniors will enroll in one of these offerings.

It’s no wonder that these flexible, innovative options are in such demand. Affordable premiums, high quality service, and the addition of dental, vision, and wellness benefits in many plans are attractive to cost-conscious seniors looking for a comprehensive partner for their care.

But administering an effective, highly rated MA plan isn’t without its challenges. From compliance and auditing to fostering true member engagement, plans must use data wisely and communicate effectively to create exceptional experiences for members.

Health plans that are able to implement the right tools, strategies, and technologies to create member-centered processes will be in the best position to achieve their goals. Doing so means understanding how to tackle their top challenges head-on and deliver the best possible care.

In this six-part blog series, we cover some of the most pressing challenges faced by MA plans along with guidance for overcoming them. We start today by introducing five critical issues and then go deep into each one over the next few weeks.

1. Staying in compliance with key regulatory requirements

Medicare Advantage plans must meet a number of very stringent compliance criteria designed to protect consumers and maintain high quality. If health plans don’t stay in compliance, there can be financial penalties or they can take hits to their public ratings, both of which are serious business problems that can be avoided with the right technology tools.

Some plans use homegrown administrative systems – or even rely on Excel spreadsheets – to complete and monitor their administrative workflows. That makes it very difficult to keep track of key compliance timelines and completion rates, not to mention identifying ways to improve processes.

Overcoming the challenge: Automating as many tasks as reasonably possible can improve efficiency and effectiveness, allowing health plans to reallocate people power and all that intellectual capital into areas that really require the human touch, like care management and member engagement.

2. Preparing for a successful CMS audit

The Centers for Medicare and Medicaid Services (CMS) keeps a close eye on MA plans with regular audits. The audit results are public and can have a significant impact on a health plan’s reputation, so it’s important for administrators to be able to demonstrate organized compliance with federal regulations.

However, it can take a lot of work to pull all the necessary information together if a plan is selected for an audit, especially if staff members are working in multiple spreadsheets or fragmented systems. Whether using a homegrown system or a comprehensive solution, the plan needs to know that Field A is going to get pulled into Report B every single time – and that they can access Report B easily if they need to show it to an auditor.

Overcoming the challenge: Health plans should consider developing an audit “playbook” that breaks down every process and includes detailed information about anything CMS might request. Plans can also prepare by conducting periodic mock audits based on CMS checklists so that all staff members are ready to run the relevant reports and able to identify any areas of vulnerability before the real assessment.

3. Addressing the social determinants of health (SDOH) for at-risk members

Healthcare stakeholders are increasingly recognizing that the circumstances in which people live, work, and play have an enormous impact on health outcomes. Medicare Advantage plans have a growing number of tools to help them address these social determinants of health. Recent changes to MA benefit rules allow plans to pay for an expanded set of services, including non-emergency medical transportation and healthy food programs.

When health plans help members meet these fundamental needs and access regular preventive care, members are more likely to stay out of the hospital and remain compliant with their care plans.

Overcoming the challenge: Health plans can begin to explore new benefit ideas by collecting and analyzing member demographic data, establishing relationships with local social service agencies, and working with contracted clinical care providers to educate members about new offerings. Making sure members’ non-clinical needs are met to the best of the plan’s ability creates a better member experience while helping health plans keep costs under control, which is a winning combination for everyone.

4. Maintaining high Medicare Advantage Star Ratings

The Medicare Advantage Star Ratings measure overall quality on a scale of one to five stars. The ratings can have a dramatic impact on a plan’s finances, advertising permissions, and other regulatory issues – not to mention member enrollment decisions.

For the 2020 plan year, 52 percent of MA plans with prescription drug benefits achieved 4 stars or higher, says CMS. But 81 percent of 2020 plan year beneficiaries are enrolled in contracts that have 4 or more stars.

The premium cost of a one-star plan typically isn’t much lower than a five-star plan, so clinical quality, administrative responsiveness, and member engagement are real differentiators.

Overcoming the challenge: Health plans that want to improve their ratings need to create a comprehensive approach to encouraging preventive care, managing social determinants of health, and personalizing experiences for their members. MA plans that can stay ahead of members’ emerging needs are the most likely to achieve top marks. For example, primary care providers need to know who is missing their flu shots before they come in for an appointment. Closing that gap afterward can be much more difficult.

Health plans will want to have a system in place to make sure they are capturing the data for each measure in a timely way and creating consumer-friendly processes to get those items checked off the list.

5. Leveraging data to prioritize quality care delivery

Data is everywhere in healthcare. Faxes, apps, portals, emails, phone calls, and even text messages all play a crucial role in making the industry work, yet few organizations have fully cracked the code on how to make sense of the deluge of information.

The first challenge for health plans is making sense of all this information and feeding it into a system to create a near-real-time view of the member. The second issue is figuring out how to analyze and prioritize important data that has a direct tie to decision-making.

Clinical teams can receive thousands of messages and alerts every week. Without some assistance with prioritization, staff members can easily start to feel overwhelmed and may miss important information for at-risk individuals. Without some assistance with identifying trends and flagging high-value information, staff members can easily start to feel overwhelmed and may not be able to close key gaps in care for at-risk individuals.

Overcoming the challenge: MA plans have to put data management tools in place that can help staff work efficiently and effectively on high priority items. A comprehensive and intuitive data analytics platform will help them achieve critical goals: staying in compliance, meeting member expectations, and producing high-quality outcomes.

Running a successful MA plan requires a patient-centered approach and creation of coordinated, data driven-processes that keep the member at the center of care while streamlining compliance and audit requirements. Implementing the right technology solutions to enable this approach ensures a win for everyone involved.