The latest star ratings issued by the Centers for Medicare and Medicaid Services (CMS) put Medicare Advantage and Part D plans on notice: Change is here to stay.
The number of Medicare Advantage and Medicare Part D plans with four or more stars fell to 42% from 51% the year before and 68% in 2022.1 Milliman called the 2024 ratings the opening bell in a “transformative phase”2 of the stars program designed to:
- Empower consumers to evaluate their Medicare Advantage and Part D plan choices with information not only on costs and coverage but also on quality of care and member ratings.
- Incentivize plans to ramp up innovation and take steps to lower healthcare costs and produce better health outcomes for millions of enrollees.
Our white paper, “How to Activate a Medicare Advantage Business for Stars Success,” explains:
- The crucial challenges facing payers today.
- The habits and practices we have observed in years of working with highly rated Medicare Advantage and Medicare Part D plans.
- How plans seeking to improve star ratings can activate their organizations and achieve stars success.
Here are some of the questions and answers addressed in more detail in our white paper (download a copy here). Then contact us, and our business solutions team will get in touch to help you activate the business of healthcare.
What challenges do Medicare Advantage and Medicare Part D plans face today?
The lower ratings for 2024 plans can partly be explained by the end of the pandemic-driven relaxation of some standards.3 But there are other forces unrelated to COVID-19 at work. They include:
- An eligible member population skewing older with more (and more costly) healthcare needs.
- A slowdown in Medicare Advantage growth among new enrollees.
- Changes to risk adjustment formulas.
- The prospect of lower reimbursements with continued emphasis on pay for performance
Many businesses are unpredictable, but Medicare Advantage and Part D businesses have challenges above and beyond what others experience, including:
- The 40 weighted clinical and nonclinical measures that make up star ratings change annually. Strengths of years past may no longer lead to higher Medicare reimbursements in the future.
- New drugs and treatments come to market, promising better health outcomes but often at steep costs.
- Healthcare providers are consolidating, limiting competition in many markets. Some providers are leaving Medicare Advantage plan networks. Other providers are forming their Medicare Advantage plans to compete with traditional payers.
What do highly rated Medicare Advantage and Medicare Part D plans have in common?
Plans that maintain and, in time, improve their star ratings realize that there’s no magic bullet, no killer app. Instead, a range of changes, tweaks, and ongoing vigilance and response work to achieve measurable improvements in members’ health and satisfaction.
We’re close observers of what distinguishes health plans that earn high star ratings from those that don’t. We’ve noted some habits they have in common and etch into their organizations’ cultures:
- Listening — They listen to their members and providers and then use their feedback to fine-tune engagement activities, benefits and programs that keep members healthy and providers performing to the highest standards.
- Analyzing — They step back from the everyday chaos and use the feedback collected along with data analytics, member and provider journey mapping, and root cause analysis to identify critical areas for improvement.
- Engaging — They evaluate their resources and capacity for taking actions to improve star ratings, and they consider the case for pulling in expertise from qualified vendors, such as nurse lines, telehealth companies, remote monitoring and engagement specialists.
- Embracing technology — They lean into emerging technologies like remote monitoring, AI, automation, and virtual and augmented reality as forces that will disrupt healthcare in the future.
- Staying nimble —They understand that changes like the upcoming health equity measure for Medicare Advantage and Part D plans will always be around the corner. They prepare for what they know is coming and have processes to move quickly when a new measure or cut point arrives.
- Committing — Whether national carriers or smaller, regional payers, highly rated Medicare Advantage and Part D plans never veer from focusing on their members’ and providers’ welfare and satisfaction.
- For more information on these habits of highly successful health plans, download our white paper, “How to Activate a Medicare Advantage Business for Stars Success.”
How do highly rated Medicare Advantage and Medicare Part D plans activate members to become engaged in their healthcare?
You’ve heard the advice, “Meet the patient where they’re at?” It applies to member engagement, too.
Not every member has the motivation or the resources to do all they should, such as taking medications to manage chronic conditions, getting regular physical activity, eating healthily, and having recommended annual visits and essential screenings.
Highly rated plans recognize these human factors and work to nurture relationships with their members over time and at a pace that members will not find threatening or judgmental. They do this in many ways, including:
- Asking, listening and applying how members want to be served. Do they prefer phone calls, mail, email, portal messaging, text or voice messaging? Or different modes for different services (e.g., text prescription refill reminders; post plan documents to the portal)? Are there roadblocks to members getting needed care?
- Measuring members’ satisfaction with benefits and programs. Highly rated plans use multiple tools — surveys, meetings, events and other methods — to get honest feedback.
- Identifying pain points or obstacles and fixing them. Does it take too long for call centers to pick up? Do members find the plan’s technology confusing or too difficult to use? Are networks — hospital, doctor, mental health, pharmacy — sufficient to meet member needs?
What is journey mapping, and how do Medicare Advantage and Medicare Part D plans use it to improve star ratings?
Members and providers have multiple touchpoints with plans across a wide range of media and instances, including:
- Communications by email, mail, telephone, text, portal or other areas.
- Calls to member and provider services.
- For providers, the processes for prior authorization of treatment or medication.
- For members, the ease with which they can find and book a healthcare provider for routine, urgent or emergency visits.
Understanding how each affects members’ health and member and provider satisfaction can help plans identify areas for improvement. That’s where journey mapping and root cause analysis come in.
A journey map is a visual diagram of every member or provider touchpoint with a health plan. Journey mapping typically occurs with representatives from departments throughout the Medicare Advantage or Part D organization. Journey mapping can help uncover the areas of vulnerability and root causes of low star ratings and illuminate opportunities for investing in transformative activities to improve star ratings.
Member and provider data also help focus a plan on areas that are likely leading to lower-than-desired ratings. Data analytics teams can unearth insights from surveys, call center recordings, health records and other sources to detect patterns such as:
- Are there days and times when call volumes are heavy but response times lag?
- How long do members typically wait to see a doctor or other healthcare provider?
- Do members live in communities where the provider network is less than robust?
- How quickly after release from a hospital are members contacted for follow-up care?
- Which members will likely be “detractors” in the annual Consumer Assessment of Healthcare Providers and Systems (CAHPS)?
Next, we suggest plans move into brainstorming solutions using “blue-sky thinking” and asking themselves how to address friction points or gaps if there were no resource constraints. Then plans can narrow their choices to what they can do and what will likely have the most significant impact on future star ratings.
How does Carenet Health work with Medicare Advantage and Medicare Part D plans to improve star ratings?
Carenet Health activates the successful business of healthcare for Medicare Advantage and Medicare Part D plans. Our performance-based health action platform leverages the power of our more than 400 licensed clinicians and 1,600 care navigators, customer analytics, and AI and machine learning capabilities.
Working with health plans, we identify opportunities for improvement and ways to address those with selective and proven solutions that engage members and providers and lead to the aims of the stars program: better health and lower costs.
Over two decades, we have supported the business transformation of more than 100 top payers and 500 providers by helping them contain costs and seize opportunities for growth in a dynamic healthcare system.
Are you interested in improving your Medicare Advantage or Part D plan’s star ratings? Contact us, and a business solutions team member will be in touch.
References
- https://www.oliverwyman.com/our-expertise/perspectives/health/2023/oct/medicare-advantage-star-ratings-offer-roadmap-for-improvement.html?
- https://www.milliman.com/-/media/milliman/pdfs/2023-articles/11-27-23_the-next-stage-of-star-ratings-evolution.ashx
- https://www.healthcarefinancenews.com/news/medicare-advantage-star-ratings-year-represent-final-fallout-covid-19
