Medicare Advantage Plans Can Boost Star Ratings with Proactive, Data-Driven Care

July 22, 2020 – ZeOmega

Medicare Advantage (MA) is incredibly popular among consumers. In 2018, more than 20 million beneficiaries, or one in three eligible individuals, chose to enroll in an MA plan. And the numbers are continuing to rise steadily.

With so many people interested in receiving coverage through Medicare Advantage, it’s no wonder that there are more than 3,000 MA plans in operation nationwide. In many counties, potential enrollees have multiple choices available to them, making it incredibly important for MA plans to stand out from the crowd.

Medicare’s Star Rating system is one way for MA plans to showcase their quality, responsiveness, and value to potential members. Plans can earn up to five stars, including half stars. The ratings provide a simple, graphical way for shoppers to evaluate MA plans against competitors.

Star Ratings can also have a profound financial impact on plans. Studies show that a one-star rating improvement could, on average, lead to an eight percent to 12 percent annual increase in member enrollment. Moving from 3 stars to 4 could increase revenue between 13.4 percent and 17.6 percent through increased member enrollment and additional bonus payments.

The ratings cover five domains gauging how well MA plans care for their beneficiaries. They are based on a subset of the HEDIS measures, a standardized set of metrics designed to assess clinical quality, service utilization, and patient experiences.

The domains include providing screenings, tests, and vaccines; managing chronic conditions; creating positive member experiences; addressing member complaints; and delivering satisfactory customer service. Beneficiaries themselves provide much of the data that determines whether a plan achieves high marks by answering standardized surveys.

Potential enrollees actively use the results to make decisions about their health plan coverage. 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 plans that have 4 or more stars.

In order for MA plans to achieve the highest possible Star Ratings, they need to leverage clinical data and high-quality healthcare providers to offer proactive care in an efficient, convenient, and consumer-friendly way.

Using data to identify opportunities to improve care delivery

Health plans will need the right technologies to proactively close gaps in care and improve consumer experience. Without comprehensive and actionable dashboards that display the detailed status of the plan’s offerings and services, health plan leaders may not be able to start gaining insight into potential areas of concern.

For clinical quality improvement, for example, data dashboards should include a variety of data sources that create an integrated view of performance across the entire provider network. These data streams should consist of claims, authorization data, care management records, and near-real-time performance statistics for key Star Ratings measures.

Health plans should also integrate information about the social determinants of health (SDOHs) that impact their members. Knowledge about the non-clinical factors that affect patient outcomes, such as social isolation, food and housing insecurity, and access to transporation can enable MA plans to better target interventions to their members. This may translate into more efficient spending, improved outcomes, and better member experiences.

The goal for health plans is to quickly identify the next steps to close gaps in care before they occur. Providers will have much better results with a list of individuals who are due for a screening in the next 60 days than they would with a list of patients whose screenings have already lapsed.

A technology platform that allows plans to share information with the right people at the right time in a concise and meaningful format will equip healthcare providers and care managers with the resources they need to meet the quality benchmarks tied to higher Star Ratings.

Curating a high-quality provider network built for success

Medicare Advantage plans may be judged on clinical care criteria, but they are incredibly reliant on their network of contracted healthcare providers to perform most of the actual work. As a result, health plans need to focus on crafting high-quality networks of providers who can deliver optimal patient care in a friendly, courteous, and empathetic manner. Read more about how one Medicare Advantage operator used ZeOmega’s Streamlined, Integrated Jiva Platform to reduce administrative burden across its clinical operations.

Bidirectional communication between the health plan and providers is critical for success and supports a collaborative relationship with shared goals and incentives. Health plans need to share their insights with providers to help stay ahead of care gaps without burying key information in reams of reports for providers to sift through.

Additionally, plans need to stay current on whether or not that information has actually translated into better care by measuring longitudinal clinical and financial outcomes. Health plans should leverage timely and accurate visibility into provider performance to prompt positive behavior changes or reconsider working with providers who continually fall short of expectations.

A clinical quality dashboard that shows detailed performance metrics down to the individual provider level can give health plans the data they need to make decisions about choosing preferred providers who consistently offer top-notch care.

Proactively engaging beneficiaries in their care

Creating a good beneficiary experience isn’t just about reducing call center hold times and delivering flu shots. It’s about helping individuals feel empowered and connected to participate in their own health maintenance and medical care.

Thanks to a tsunami of new consumer-facing technologies, beneficiaries are increasingly taking on more responsibility for their health. From smartphone apps and remote monitoring tools to Bluetooth-connected medical devices, health plan members have numerous tools at their disposal to stay on top of their wellbeing.

Health plans can take advantage of these tools, too, by supporting beneficiaries who want to get more involved in their healthcare. This may include offering an app that provides information about covered services, cost comparisons, and nearby providers. It may also mean text messaging members with reminders about due dates for their next colorectal cancer screening or diabetic eye exam.

Communicating frequently with members according to their personal preferences has multiple benefits for both the health plan and the consumer.

First, it allows beneficiaries to manage their own needs, ask informed questions about their care, and advocate for themselves when necessary. Patients who receive reminders about preventive services may be more likely to raise the issue during a visit if a provider forgets to mention it.

Second, personalized messaging helps beneficiaries feel like their health plan is genuinely looking out for them, which can improve the plan’s reputation and generate better member experiences, which can ultimately translate into higher Star Ratings.

Plan responsiveness and the availability of services are two major categories within the Star Ratings, so health plans that offer meaningful support and clear channels of communication are likely to achieve higher marks from members.

Combining all three pieces of the puzzle – plans, providers, and patients – into a seamless communication loop can support better outcomes for everyone.

By adopting data-driven strategies to identify opportunities for improvement, creating strong provider networks, and nurturing meaningful relationships with members, Medicare Advantage plans can achieve Star Ratings that truly reflect the high quality of their care.