“Why are payers still struggling with a lot of complicated tasks? What holds the key to solving their problems?”
Would you be surprised if the answer to the above question is patients themselves?
Although payers are fairly young in the US healthcare dynamics, they have become a substantial element in the transforming value-based healthcare. 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.
Often the things that are missing end up making the most difference, and so is the case with providing patient-centric care. We may put in all our efforts into improving the patients’ health, but finding the missing piece of information for payers is the biggest challenge of it all. And then there are reviews, audits, HEDIS measures, and most of all, STAR Ratings.
Why are STAR Ratings such big shots 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.
Going forward, the STAR Rating evaluation will be more crucial for not just the payer organizations but also for the providers. CMS is aiming for saving $2.2 billion over ten years for Medicare, something that would be in the line of advancing the goal of accountability, engagement, integrity, competition, and quality.
The complicated web of data for payers
About 60% of the US population suffers from at least one chronic disease, and many of them fail to adhere to their treatment regimes. A great number of patients are not able to follow-up on their physicians after an episode or a surgery effectively. There are many such cases and they account for higher admissions, readmission, ED visits, and many more.
The biggest challenge is that the data systems in healthcare do not communicate, and in turn, obstruct the connectivity between payers and providers. Be it patient charts, lab results, physician notes— all of these have crucial information to provide, but before that, they have to be brought together so that they could provide a clear picture of where the improvement is required.
The guide to capturing the fifth star with effective care management
Care management and payer performance go hand in hand. We cannot deliver true patient-centric care if payers are not able to get their hands on the most crucial data elements to act as an auditor. A while back, I came across a survey by McKinsey and Company which stated that only 21% of Medicare Advantage plan enrollees knew their plan’s STAR Rating.
Payers need to collaborate with physicians to build a mechanism for them to support patient-health initiatives at every step. For scoring a higher STAR Rating, they need to ensure that their patients receive appropriate care and they 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:
The road ahead
Risk adjustment programs are designed to financially reward payers with higher medical loss ratios (MLRs) to ensure that they enroll high-risk beneficiaries. 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 changing healthcare, need payers and providers to work together, and we need payers, providers, and leaders to come together for a greater cause to delivering the care every patient deserves.
To know more on how you can improve your STAR Rating with a unified healthcare data platform, get a demo.
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Join Dr. Paul Grundy, ‘Godfather’ of Patient-centered Medical Home along with Dr. David Nace, CMO at Innovaccer in our latest webinar, “Key Drivers to Build a World Class Patient-centric Healthcare,” on 25th September, at 10:00 AM PT/12:00 NOON CT.