Healthcare

How can Medicare Advantage Plans Achieve Maximum Star Ratings with FHIR-enabled Data Activation Platform

Abhinav Shashank
Mon 04 May 2020
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While healthcare leaders uniformly agree that transitioning to value is the way healthcare is going to be in the coming days, it is unclear to most how they can make the transition without negatively impacting their cost outcomes. In an industry that had primarily been fee-for-service based, healthcare organizations are facing immense pressure to innovate and adapt or risk their long-term viability.

In developing strategies to succeed with these trends, many healthcare leaders are realizing that Medicare Advantage (MA) is a key component for their long-term success. The Centers for Medicare and Medicaid Services (CMS) has projected that Medicare Advantage enrollment will reach an "all-time high" in 2019 with 22.6 million Medicare beneficiaries, given the unprecedented growth. And industry analysts like L.E.K. Consulting say that Medicare Advantage enrollment will rise to 38 million, or 50% market penetration by the end of 2025.

Going along the same lines of ensuring long-term success and enhanced patient satisfaction, CMS rates Medicare Advantage plans by giving them Star Ratings which help beneficiaries and their family members make informed decisions. As MA Star Ratings become the most visible mark of success, the only trail of thoughts would be: How to improve these Star Ratings?    

How do Star Ratings work?

The Medicare Star Ratings are key measures of the quality of care a health plan provides. The health plans are rated on 45 measures categorized under 5 categories which portray how a health plan takes care of its beneficiaries.

Needless to say, there’s a lot at stake here. The more Stars a health plan has, the more likely they are to attract beneficiaries. But earning top ratings is a difficult task. Payers that wish to reap the benefits of high Star Ratings also need to deliver impeccable care to their members and ensure a satisfactory experience of care.

The current trends of MA plan performance

The growth trajectory of the Star Ratings of health plans between the year 2017-2020 has been remarkable. The weighted average of the plans awarded four or more Stars increased from 70 percent to more than 90 percent, even after accounting for an increase in the number of plans. Most MA plans have been successful in cracking the code to earning lucrative Star Ratings. 

However, along with other MA plans, plans having four or more Stars must continue to improve their performance metrics to sustain their high ratings. CMS is set to add more parameters to intensify the momentum to drive better quality, health outcomes and reduce costs. When a health plan achieves the maximum ratings for a measure, CMS has the authority to dismiss the measure and introduce a new one to further incentivize quality improvement. 

What steps should MA plans take to increase their Star Ratings

The increase in Star Ratings is directly proportional to the increase in beneficiary enrollment and revenues. Here are some measures that MA plans can take to improve their Ratings:

  • Data-driven insights into the patient population

Healthcare organizations should be provided with real-time insights into their patient population. With the right data at their disposal, they would be able to plan better interventions and suggest the right courses of action for their patients.

  • Interventions based on socioeconomic and financial conditions

As per the new regulations, healthcare organizations can test non-uniform benefit designs to provide reduced cost-sharing or additional supplemental benefits for the Medicare Advantage enrollees based on their socioeconomic or financial condition. In this way, they would be able to target the right audience considering the non-clinical aspects instead of providing care based on clinical data alone.

  • Smarter patient engagement with a strong telehealth network

Healthcare organizations can increase patients’ access to telehealth services by allowing plans to propose the use of telehealth services instead of promoting in-person visits. Not only is this helpful in reducing the utilization cost in the network, but would also be easier for patients.

  • Comprehensive care management across the network

To increase patient satisfaction, MA plans must ensure a timely, coordinated approach to wellness and health care planning. With an efficient care management approach, providers can offer the best care services to not just the MA enrollees, but also other patients in the network.

The road ahead

The fact that the US healthcare is evolving and the change has been more focused on delivering holistic, centered care to every patient is proof of the growing ‘consumerism’ in the healthcare space. Patients now want more facilities to be included in their care services. The success or failure of any organization or plan is based on the level of satisfaction that they help their patients achieve.

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