How Payers Can Increase Their Star Ratings with Effective Care Management

Abhinav Shashank
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“Why are payers still suffering with tedious grunt work? What could be the solution to their problems?”

Would you be surprised if the answer to the above question was patients themselves?

Even though the payer segment is relatively new in the healthcare sphere, they have become significant players in the transition to value-based care. Considering the current pace with which we are evolving in terms of delivering quality care, it would become quite difficult to realize the dream of efficient healthcare if we leave payers behind.

What makes STAR Ratings so important for everyone?

CMS STAR Ratings directly impact the revenue for Medicare Advantage (MA) plans. Higher ratings bring better quality bonus payments (QBP) for payers, and on the other hand, lower ratings bring penalties and in the worst case, termination.

The key to getting the fifth star with effective care management

Payers need to take steps to join hands with physicians to devise methods to support them in their patient-health initiatives. The way to increase STAR Ratings is to ensure that their members receive appropriate care and are aware of what is happening to them. Here are the four key steps in developing a better patient-centric environment and ensuring higher returns on investment:

1. Go beyond planning your data, plan your approach

Payers need to identify their ability and assess each measure corresponding to their ability to better understand how it will affect their summary score. In addition, to understand their performance, they need data not just from traditional EHRs or claims records, but from other sources such as practice management systems (PMS), financial systems, ADT feeds, pharmacy, and many more.

2. Empower the physicians and care teams in your network

Providers can contribute to improving overall quality scores in many ways. With empowered and connected physicians and care teams, payers would be able to track the performance of each member on every reporting measure. Once they ensure streamlined information management on-the-fly, they can help in reducing physician burnout, patient fall-rate, erroneous reimbursements, and a lot of other factors.

3. Identify the at-risk and high-risk patients

Segregating the patient population on the basis of risk scores and other relevant factors to make out which patients need the most care is a very important step for both payers and providers. Factors such as Length of Stay (LOS), hospital readmissions per 1,000, ED visits, patient satisfaction scores, among many, contribute to the performance of providers and payers and their need to understand the actual number to these measures— right at the point of care.

4. Establishing automation

Eliminating manual work, such as acquiring member charts from providers, can greatly contribute to the efficiency of the payers. Manual work obstructs them from diving deep into the roots of the care gaps. The best possible way to simplify the process is to enhance the connectivity among multiple health systems through automation. 

The road ahead

Payers are an integral element in understanding different segments of healthcare as they direct the bulk of healthcare dollars. We need evolving partnerships. We, as members of a changing healthcare field, need payers and providers to work together, and we need payers, providers, and leaders to come together for a greater cause— to deliver the care every patient deserves.

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