Data-Driven Relationships Catalyze Quality for Medicare Advantage Plans

August 21, 2020 – ZeOmega

For Medicare Advantage health plans, quality must remain the priority.

Quality, as measured through compliance audits and the consumer-facing Star Ratings, is key for sustainability and growth. MA plans that wish to truly outperform the competition need to think of quality in terms of providing value to their members. Data-driven connections that enable better care experiences for everyone involved are key for achieving this goal.

MA plans realize value by managing the three key relationships in healthcare continuum: the patient-provider relationship, the member-health plan relationship, and the provider-health plan relationship.

In all of these pairings, health plans can take an active role in reducing friction and generating value, thereby meeting the Quadruple Aim of lower costs, better health for populations, better patient experiences, and improved provider experiences.

As value-based care continues to expand, the industry has sharpened its focus on the patient-provider aspect of the puzzle. Proactive providers and engaged patients are critical in a pay-for-performance environment – yet MA plans cannot afford to put their relationships with members and providers on the back burner.

High-performance healthcare providers are at the core of any successful MA program. Health plans need to ensure their healthcare providers are operating as trusted partners and not as obstacles for their provider networks.

Additionally, since there is so much choice available to consumers, a strong bond between members and their plans will create informed, empowered, and brand-loyal individuals who can make smarter choices about their care.

(Related reading: Meeting CMS requirements for interoperability and patient access)

To achieve harmony across all these connections, MA plans need to equip their partners with personalized, meaningful data. Providing actionable insights to members and care providers can enhance outcomes while reducing costs and improving efficiency across the care continuum.

Laying the groundwork for positive partnerships

Under fee-for-service, health plans often struggle to overcome negative perceptions of their role in controlling spending, especially as increasing price transparency helps to inform consumers about their choices. With value-based care, however, MA plans have the opportunity to work more collaboratively with members and providers to achieve shared financial and clinical goals.

Medicare Advantage members often experience multiple chronic conditions and other complex health issues that require close management and care coordination. Value-based care provides the framework for MA plans to get more involved in supporting members through these challenges.

Educating patients about this new paradigm, clearly explaining available services, and offering multiple communication options based on consumer preferences will help activate members and build rapport.

Likewise, a well-informed provider is a health plan’s greatest asset for improving quality and producing results for members. Providers that work well with their MA plans are likely to exhibit higher marks on important quality and cost indicators.

MA plans can then select these providers as part of their preferred networks, making it easier to guide members toward top performing clinics. As a result, patients will receive better care and providers will work proactively with their MA plans to deliver cost-conscious, highly effective services.

MA plans that build trust and credibility with their providers will start to open channels of communication that help improve utilization, member management, and the authorization process.

Actionable data as the fuel for the plan-provider relationship

To establish this trust and achieve quality and cost goals, MA plans will need to invest in strategies and technologies to promote two-way communication and smoother interactions.
Most health plans already offer a provider portal, but few of these tools augment the clinical workflow in an intuitive, actionable way. In many cases, poorly designed portals are worse than no portals at all. Not only will important information sit idle, but providers will view the health plan negatively for offering a technology that is frustrating, overloaded with messaging, and difficult to manage.

In many cases, poorly designed portals are worse than no portals at all.

MA plans need to implement portals that are easy to use and deeply integrated into the EHR workflow. The right portal will contain clinical intelligence targeted to the user’s needs and immediate priorities, such as care reminders, population health management recommendations, and provider performance metrics.

Health plans can also support frictionless plan-provider relationships with automated authorization requests and approvals where appropriate, allowing providers to deliver care more quickly and efficiently for their patients.

This is a key part of meeting the “improved provider experiences” component of the Quadruple Aim.

Monitoring provider performance and sharing that information with clinical partners in a proactive manner is equally important for maintaining trust and quality. MA plans can help providers improve by delivering educational resources and reports on adherence to evidence-based protocols, patient outcomes, and spending patterns. This data will allow providers to understand where there are opportunities for improvement and adjust their workflows and care models accordingly to drive quality outcomes.

Empowering members with personalized communication

Members also need guidance from their MA plans to make informed choices about care and understand why certain decisions are being made about services or treatments. Proactive, situationally appropriate communication with members can establish shared goals and clarify expectations to maintain meaningful member-plan relationships.

To successfully work with members, MA plans need to understand what motivates their members. Plans will need to adopt tools and strategies to analyze member data, including their clinical challenges, social determinants of health, readiness to change, and other behavioral triggers. Tailored questionnaires based on the member’s age, life circumstances, or socioeconomic status can help to meet members where they are in their health journey – even if they are not making as much progress as the plan would like.

For example, not every individual who uses tobacco is ready to quit the habit. Offering a smoking cessation plan for a person who has adamantly told their provider they are not prepared to stop can result in wasted resources while stirring up resentment in the member. Instead, MA plans should use personalized care management technologies, such as tools that can require an affirmative response to a supplementary question about “readiness to change” before triggering the smoking cessation process.

This can turn a potential conflict of interests into an opportunity for discussion about developing new habits. The plan and provider can allocate their resources more appropriately while making the member feel respected and valued as an individual.

Leveraging data-driven processes for long-term success

Medicare Advantage plans face a number of challenges in a thriving, highly competitive marketplace. From maintaining compliance and addressing the social determinants of health to achieving high Star Ratings and building quality relationships, MA plans need to leverage all the tools at their disposal to perform well.

The right technologies are crucial for creating visibility into the performance of the plan and its provider partners while enabling personalized communications with existing members and potential consumers. As more and more seniors look to MA as the solution for their healthcare needs, plans must invest in tools that create targeted, member-friendly experiences while controlling spending and avoiding waste.

Developing data-driven workflows that allow for informed decision-making will empower MA plans and their partners to maintain high quality and deliver exceptional care to those who need it most.