Launched in 2003, Medicare Advantage (MA), Medicare’s managed care program, is gaining steady ground. Today, 16.8 million beneficiaries – 31 percent of the Medicare population – are enrolled in MA plans, a 50 percent spike from 2010, when the U.S. enacted healthcare reform legislation.

Shaping a system for plan comparison

To help consumers and caregivers easily compare MA plan performance, the Centers for Medicare & Medicaid Services (CMS) created the Five-Star Quality Rating System. CMS uses 32 measures for MA-only contracts and 44 measures for MA with prescription drug coverage to rate plans on a scale of one star (poor) to five stars (excellent). The measures span five broad categories – outcomes, intermediate outcomes, patient experience, access, and process. With these ratings, Medicare beneficiaries can gauge quality of care and customer service to make more informed choices in health plan selection.

Seeking top ratings

According to David Lucas, vice president of strategic business at Vivify Health, a fast-growing international digital health company, health plans have compelling reasons for pursuing four-star to five-star ratings. Higher scores mean:

  • More money. Star Ratings serve as the basis for CMS quality bonus payments (QBPs), representing about 5 percent of total Medicare reimbursement. Bonuses begin with a four-star rating and can be as high as $500 per member. For the larger health plans, this can equate to an additional $1.5 billion in annual revenue.
  • More flexibility. With a five-star rating, an MA plan can enroll new members at any time of the year, as opposed to only during limited enrollment periods.
  • More members. The higher the Star Rating, the greater the likelihood of capturing the interest of member prospects. QBPs can be channeled into additional member benefits, as well as reduced premium costs, helping plans attract more enrollees and increase profits.

Setting a high bar

Seniors’ choice of high-performing plans is on the rise. CMS reports that about 60 percent of beneficiaries were enrolled in a four- or five-star plan in 2015, compared with an estimated 17 percent six years earlier. Yet the numbers also tell the story of how challenging it is for plans to become – and remain – high performers in the annual Star Ratings Program. An analysis of 2015 ratings finds that less than half of MA plans achieved above-average or excellent ratings: 22%, four-star; 15%, four-and-a-half star; and 3%, five-star.

Staying healthier at home

An estimated 83% of a health plan’s MA members have chronic disease. Effectively engaging with and shaping the behavior of these members is the “secret sauce” in achieving higher scores, Lucas notes. CMS is increasingly focused on chronic disease management, weighting health outcomes three times more heavily than process measures in calculating a plan’s overall Star Rating. To improve outcomes and reduce costs, future-focused MA plans are launching remote monitoring with connected care programs. These programs aim to shift care from expensive, acute settings into the home while helping members better manage their conditions through interactive engagement.

Succeeding in star performance

With an end-to-end remote monitoring platform, MA plans can keep a vigilant eye on their at-risk membership to reduce costs and improve clinical outcomes. “When we created our platform years ago, we recognized our customers needed a flexible model of technologies and services administered from the same common backend and in support of all clinical use cases,” Lucas says. “This is especially so with our health plan customers, who assume full risk for their membership across varied risk profiles and assorted clinical challenges. The flexibility of this platform assures our customers of matching the right remote care technology with the right risk profile and clinical condition in the most cost-effective way possible.” He explains that remote care monitoring can help plans to:

  • Intervene quickly. A robust remote care management program regularly collects member biometric and useful qualitative information designed to yield insights into the member’s current and trending health conditions. The care team is proactively informed of changes in a patient’s health status and can take immediate action, potentially averting adverse events.
  • Apply appropriate resources. The MA plan can choose between its own care coordination resources for monitoring versus the turnkey option of an expert third-party remote service, tightly integrated with the plan for triage and escalation protocols.
  • Reduce utilization. Whether through averting a preventable hospitalization, a readmission, or an ED visit, remote care can help proactively reduce the incidence of unplanned and unnecessary utilization.
  • Lower costs and improve care quality. A highly economical way of engaging members, remote care management technology could save as much as $36 billion in healthcare costs worldwide by 2018. At the same time, it provides the opportunity to improve care quality through increased member health education, interactive engagement, and eventual shaping of behavior.
  • Put first things first. “Meaningful engagement must precede improved health outcomes,” Lucas says. “The most effective remote care monitoring platforms provide a simple, controlled, and instant-on experience with the ability to customize protocols and pathways for each individual member. Moving a non-tech-savvy 77-year old into the realm of daily long-term compliance with technology requires the ‘easy button’ so that individuals can quickly embrace and appreciate being connected to those who care about them.” Once this engagement is locked in, he notes, a healthier and happier member results – a key contributor to higher Star Ratings.

Stratospheric changes in healthcare financing will continue to challenge MA plans, catalyzing them to readily adapt their business models, rigorously improve their Star Ratings, and resolutely reduce risk. In this rapidly evolving and rampantly competitive environment, plans that innovate through remote care management programs – to prevent serious health events, create care efficiencies, and foster trusting member relationships – are destined to rise and shine.

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1 Comment

  1. Some great insight

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