How to Address SDOH and Medication Adherence to Improve Star Ratings Outcomes for Dual Special Needs Plans

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The most recent data from the Centers for Medicare and Medicaid Services (CMS) estimates that across the United States, there are more than 12 million consumers dually eligible for Medicare and Medicaid. Of that population, 37 percent are reportedly enrolled in Medicare Advantage Dual Special Needs Plans (DSNPs). These dually-eligible consumers often have high rates of chronic illness, behavioral health conditions and long-term care needs.

Patients with chronic conditions are also more likely to experience social determinants of health (SDOH) challenges compared to non-dually eligible Medicare Advantage enrollees. According to ACAP, some of the most common SDOH needs of dually eligible consumers include lack of access to transportation, food insecurity and social isolation or loneliness.

The COVID-19 crisis has brought to the forefront in a very short time just how much of a role these SDOH factors and other quality of life issues can play in consumers’ overall health and outcomes. More than 60 percent of dual-eligible consumers have multiple chronic conditions, which puts them at high risk of becoming seriously ill if they contract COVID-19.  As a result, dual-eligible consumers have been hospitalized at a rate more than 4 times higher than consumers with Medicare only.

The Disproportionate Impact of SDOH on Medicare Advantage Star Ratings

Pandemic or no, unmet SDOH factors can make it difficult to access and follow care recommendations and medication regimens, resulting in poor medication adherence, avoidable hospitalizations and emergency department visits. In turn, these vulnerable patients with chronic conditions often have poorer health, higher utilization rates, higher healthcare spending and lower-quality measure scores. For Dual-Eligible Special Needs Plans (D-SNPs), these factors negatively affect Medicare Advantage (MA) Star Ratings, which determine plan eligibility for value-based bonuses from CMS.

MA plans that serve this uniquely challenging population have historically struggled to achieve the 4-star threshold needed to qualify for Medicare Quality Bonus Payments (QBP). That struggle is about to get even more difficult — and not just because of the pandemic. Starting in contract year 2021, Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures are quadruple-weighted, meaning the consumer experience surveys will now make up 32 percent of a plan’s overall Medicare Advantage Star Ratings. Unlike other quality measures, CMS will not provide D-SNPs with a curve when measuring CAHPS performance.


In contract year 2018, D-SNPs performed 5.8 percent worse for CAHPS measures as compared to non-DSNPs. That was when CAHPS measures carried a weight of 1.5x. The new weighting shift to 4x in 2021 could have a tremendous negative impact on D-SNPs. Plans that fall below the 4-star threshold risk losing approximately $450 per member per year reimbursement improvement as a part of the nearly $11.6 billion annual QBP pool allocated by CMS. Because the QBP pool is finite, it is Darwinism for healthcare; only the plans with the strongest-quality plans can compete. D-SNPs that receive a QBP are required to improve member benefits or reduce premiums, thereby building a better product to compete for consumers in years to follow.

Medication Adherence: A Pathway to CAHPS Success

Most D-SNPs already work to address SDOH factors, but these plans almost exclusively rely on antiquated case management tools, spreadsheets and transactional measures campaigns to close gaps in care. The pandemic combined with CMS’s new emphasis on CAHPS has added a new layer of urgency and complexity to the process. To improve MA Star Ratings outcomes and avoid a potential downward spiral, MA plans will need to adapt old strategies and find new, more effective ways to tackle SDOH and key Star Ratings measures to ensure consumers experiencing greater socioeconomic challenges can continue to access needed care — a key focus of CAHPS surveys.

Addressing SDOH issues as part of proactive, data-driven medication adherence outreach has been proven to show improvement. An analysis of Medicare Advantage Part C and D measures for the 2021 contract year reveals 52 percent of experience improvement, process and outcomes measures are anchored to medication adherence. Further, there are two 5x weighted measures that are also impacted by CAHPS measures: health plan quality improvement and drug plan quality improvement. Medication-related measures, therefore, can effectively serve as an anchor for all other quality improvement activities, most notably those focused on CAHPS.

Under normal circumstances, only 50 percent of patients adhere to medications as prescribed, a number that has likely increased in the wake of coronavirus because of disruptions in medical care and a worsening economy. By leveraging predictive data and telehealth services to find and reach these patients, clinicians are often able to organize interventions that improve patients’ access to medication, transportation, electricity and nutrition. That could mean connecting them to a local food delivery service, clarifying how and when to take their medications or arranging for private courier deliveries for their prescription refills.

Indeed, the best way to overcome SDOH for these at-risk consumers is to provide them with tangible resources, which could include transportation assistance, help with scheduling telemedicine appointments or connections with community resources. Resources such as transportation options, digital pharmacies and prescription delivery services will not only help resolve medication nonadherence but also increase access to needed healthcare and improve overall public health. This type of proactive outreach is imperative to help keep dual-eligible consumers out of the hospital at a time when hospitals need every bed open.

The Role of SDOH Data Collection

Having the ability to collect, store and access data surrounding SDOH while simultaneously mapping the data to medication adherence measures is crucial to success, but remains a significant challenge for many plans. Most plans don’t have the right tools or technology to manage the information. In addition, consumers might be wary of revealing necessary information to their insurer or provider. And providers often do not have the time, tools or comfort level to have conversations with patients about their housing, access to healthy foods, transportation or other SDOH hurdles.

The first step in adequately capturing SDOH data is knowing the right questions to ask. Ideally, clinicians who conduct consumer outreach on behalf of a plan should be educated on social issues and understand what information needs to be collected. They should also be familiar with resources and places within the community to which they can refer consumers and provide patient education. There are a number of factors to consider.

Food Insecurity

Food insecurity has always been a major social determinant of health. New analysis shows it’s a problem for nearly one in 10 Medicare enrollees age 65 and over with long-term disabilities. And as Americans continue to face many hardships due to the COVID-19 pandemic, addressing food insecurity is a growing priority. If a dual-eligible consumer is already diabetic or suffers from heart disease, not having access to enough healthy food to eat can make the matter worse. This is why beginning in 2020, CMS allowed plans to cover benefits such as meal delivery for people with chronic conditions.

Lack of Access to Transportation

According to the American Hospital Association, 3.6 million people in America do not receive healthcare because they do not have access to transportation. It’s among the most important SDOH issues for seniors with long-term disabilities, because missed appointments can have serious medical consequences. Whether that is due to not owning a vehicle, the time it takes to reach health activities and services, or any of a myriad of other restrictions, transportation tends to get in the way and can interfere with continued access to needed medication. Medically complex patients with challenging social determinants of health often benefit from private courier-delivered pharmacy services, which eliminates the need for travel to and from the pharmacy even if the consumer still needs transportation for provider appointments.

Social Isolation or Loneliness

Social isolation and loneliness have emerged as a large focus for the Medicare population, particularly in the wake of COVID-19, which halted face-to-face interactions as well as social activities in senior centers, churches and with family and friends. Seniors with long term disabilities are particularly at risk for loneliness, as they may be more likely to face mobility challenges. Studies have found that social isolation is a risk factor for a range of physical and mental health conditions, including heart disease, obesity, diminished immune response, depression, and anxiety. The dually eligible population often benefits from services such as Papa, which connects health plan members to college students who provide in-person or virtual companionship for seniors.

Using Analytics to Identify At-Risk Consumers and Personalize Support

Addressing SDOH issues to improve poor medication adherence and ultimately improve MA Star Ratings outcomes for D-SNPs and other MA plans is possible if you apply a strategic lens to the problem and use data to drive your outreach. Robust analytics can advise when a plan consumer starts a new daily medication to monitor as well as identify SDOH issues impacting medication adherence.

A key to success is reaching the right consumers at the right time and using a customer relationship management (CRM) tool to engage consumers over time in a holistic way that leverages every touchpoint with consumers. Use a data-driven tool to target consumers with gaps in care or who are non-adherence, and make SDOH issues a priority in every conversation.

SDOH issues impact consumer healthcare in different ways; there’s no one-size-fits-all approach. When you begin to personalize touchpoints based on specific consumers’ challenges instead of using blanket or disconnected communication plans, you have a better chance of enhancing access to healthcare.

Ultimately, you need consumer experience to be the foundation of all interactions. When you take a data-driven approach to identify and engage these consumers, you can proactively connect them with available resources that are pertinent to their current individual situation. Consumers who face complex SDOH challenges, as many D-SNP consumers do, cannot always prioritize their medication. Work with consumers to make sure their basic needs are met, and then turn your focus to medication adherence once the consumer has reliable access to food and transportation.

Programs that focus on SDOH and medication adherence may specifically help reduce ED visits, the misuse of medications and avoidable hospitalizations. Having a team with specialized expertise and an SDOH-focused technology platform enables you to match plan consumers to the right kind of support.

Resolve™ empowers health plans to target consumers for more successful engagement and SDOH support over time. It’s a powerful, consumer-centric, analytics-driven tool that addresses more than 80.5 percent of Medicare Advantage Star Rating weightings, including CAHPS and medication-related measures.