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The Medicare Advantage Star Ratings heavily favor health plans that can effectively engage high-risk members who often struggle with medication adherence and access to chronic disease management resources. How can plans reach these challenging populations to boost their ratings and improve outcomes?
For Medicare Advantage (MA) health plans, the Star Ratings system is a critical opportunity to showcase positive results in a dynamic, highly competitive marketplace. The public-facing ratings are hugely influential in member decision-making, not to mention that high performance is required to access quality bonus funds and enhanced marketing opportunities.
To achieve the highest rankings, MA plans need to focus on several key areas, including member experiences and medication adherence – especially among high-risk, high-complexity members.
CMS has focused plans to solve patient experience and health equity to support members getting the best outcomes. In the current performance year, patient experience, medication adherence and medication-related quality measures account for 80.5 percent of the total Star Ratings score. The alignment of social determinants of health (SDOH) and evidence-based medication use force MA plans to have unique strategies to support their high-risk populations.
Health plans that hope to hold onto their top marks in this pressure-filled environment will need to make a concentrated effort to identify, engage, and address the holistic needs of high-risk individuals. Here’s how they can get started.
Leverage Multisource Data to Create a Portrait of High-Risk Populations
MA plans should begin by making sure they fully understand their high-risk members and the circumstances in which they live.
“We always say that it’s the zip code, not the genetic code, that has the most influence on health,” says Jason Z. Rose, CEO of AdhereHealth. “Health plans need to be abundantly clear about their members’ socioeconomic challenges. Combining multiple data sources into actionable insights helps you visualize areas of geography that contain members who need targeted, enhanced services to address their socioeconomic needs.”
Plans should consider three main data layers to help them identify pockets of members who could benefit from additional support, including:
- Publicly available data: The CDC Social Vulnerability Index provides an important foundation for gaining insight into SDOH barriers. For example, plans can analyze criteria such as household composition, disability, housing type, transportation, and language preference, which will allow them to pinpoint different geographic areas with the highest levels of vulnerability.
- Claims and utilization patterns: Most plans already analyze pharmacy and medical claims to monitor spending and identify their highest-cost members. But plans must go a step further by understanding how these individuals move through the healthcare system and experience barriers or gaps in their care. Many times, there is an SDOH component to abnormally high spending.
- Member engagement data: When health plans build infrastructure to collect standardized, meaningful data about members’ non-clinical barriers, they start to develop insights into Maslow’s “hierarchy of health needs” (e.g., food, shelter, financial access to needed care and pharmacy, transportation, health literacy, vaccine hesitancy) and how to design personalized engagement. Removing these barriers to care will build Stars momentum to improve adherence and other quality outcomes.
Design High-Impact Strategies for Messaging and Engagement
The highest-risk MA members need different engagement strategies from other member groups. Sometimes these individuals have not had a positive experience with the health system in the past. Perhaps they’ve experienced too much bureaucracy, impersonal treatment, or too much hustle just to get them out the door.
With very high-risk members, plans only have moments to grab their attention and keep them from hanging up the phone. Messaging must be succinct, specific, and – most importantly – helpful to their individual needs. They will never follow up if they don’t understand the basic information necessary to make good decisions about their own health or if they have to go dig for information. In other words, health plans should avoid treating patient engagement as a check-box exercise – they might be lost to you after that.
Members don’t want to be treated like a cog in a statistics mill and don’t want their health plan to call and ask for something. Members simply want to know what their plan is going to do for them. If health plans can connect on a more personal level and successfully remove an individual’s barrier to care on the first call attempt, they will answer the phone the second time, which opens the door to meaningful long-term engagement.
“When we do a medication adherence check, we don’t ask someone if they took their meds,” Rose explains. “We ask them what’s going on in their lives that might make it difficult for them to take their meds. We’re not nagging. We’re offering an opportunity for them to be heard. And we don’t just make a two-minute phone call. We have five or six calls a year – 15 or 20 minutes at a time – to build momentum with that relationship and develop trust.”
Health plans should consider training their clinical engagement team in motivational interviewing techniques that are effective in building connections and letting members express their concerns, challenges, and strengths. By flipping the script, plans may be more likely to achieve their internal goals without alienating hard-to-manage members.
Focus on Medication Adherence with Pharmacy-Centered Outreach
Ideally, outreach efforts should be rooted in the pharmacy. Medication adherence is a huge part of the Star Ratings and it is so deeply connected to members’ overall habits and barriers to engaging with the healthcare system. If you can help these higher risk members, with triple-weighted adherence measures and quadruple-weighted CAHPS patient experience measures, the results will boost the overall Star Rating for the plan.
The power of a pharmacy-centered approach should not be underestimated. Take an AdhereHealth case study of a 4.5-Star plan with approximately 200,000 members for example.
Using aforementioned data strategies, AdhereHealth identified this plan’s highest risk members and drove engagement through telepharmacy outreach, achieving a connect rate of more than 54 percent by working closely with their providers and pharmacies to get contact information that was not available through eligibility data.
The average talk time was 16.4 minutes with these individuals as AdhereHealth worked through the barriers that prevented them from getting their medications. As a result, the plan saw a steady year-over-year increase in diabetes adherence, RAS adherence, and statin adherence for four years. That is extremely positive for the health plan, but even more so for the members who are getting their chronic conditions under control.
As the Star Ratings continue to zero in on member experiences and medication adherence, MA plans will need to quickly adapt their strategies to meet the needs of their most challenging populations.
“There will always be a subset of patients who are very difficult to manage and require a different approach from the rest,” concludes Rose. “If you are a 3.5 Star plan cusping on that 4 Star achievement, you might need to look at broader strategies for engaging all your members better.”
“But if you’re comfortably above 4 Stars, you likely already have a good program in place for 80-85% of the membership. However, the harder to reach and unengaged members in the 15-20% of adherence scores require the plan to use some of these techniques to ensure higher risk individuals get the holistic, socioeconomically appropriate care they need.”
