Electronic Health Reporter

By Abhinav Shashank, co-founder and CEO, Innovaccer.

While healthcare leaders uniformly agree that transitioning to value is the way healthcare is going to be in the coming days, it is unclear to most how they can make the transition without negatively impacting their cost outcomes. In an industry which had primarily been fee-for-service based, healthcare organizations are facing immense pressure to innovate and adapt or risk their long-term viability.

In developing strategies to succeed with these trends, many healthcare leaders are realizing that Medicare Advantage (MA) is a key component to their long-term success. The Centers for Medicare and Medicaid Services (CMS) has projected that Medicare Advantage enrollment will reach an “all-time high” in 2019 with 22.6 million Medicare beneficiaries, given the unprecedented growth. And industry analysts like L.E.K. Consulting say that Medicare Advantage enrollment will rise to 38 million, or 50 percent market penetration by the end of 2025.

Going along the same lines of ensuring long-term success and enhanced patient satisfaction, CMS rates Medicare Advantage plans by giving them Star Ratings which help beneficiaries and their family members make informed decisions. As MA Star Ratings become the most visible mark of success, the only trail of thoughts would be: How to improve these Star Ratings?

How do Star Ratings work?

The Medicare Star Ratings are key measures of the quality of care a health plan provides. The health plans are rated on 45 measures categorized under five categories which portray how a health plan takes care of its beneficiaries.

Needless to say, there’s a lot at stake here. The more Stars a health plan has, the more likely they are to attract beneficiaries. But earning top ratings is a difficult task. Payers that wish to reap the benefits of high Star Ratings also need to deliver impeccable care to their members and ensure a satisfactory experience of care.

What holds MA Plans back from achieving better Star Ratings?

A majority of these measures are defined on the basis of specific service received, claims, or clinical information that verifies access and delivery of care. For example, if there is a large number of members that have a chronic disease, plans can pinpoint them and identify the specific care they have received during the year. After that, they can plan targeted interventions to close the gaps and be on the path to deliver positive outcomes.

However, with limited actionable member data available, MA plans just end up focusing on broad, general interventions as compared to undertaking a member-specific, targeted approach. MA plans require timely and detailed information about their members’ health to create interventions that have a lasting impact.

Additionally, it’s important to realize that beneficiaries don’t just have high-quality care, but also have quick access to healthcare service. MA plans need to ensure that the quality of care is always upheld. In most cases, it stems out of efficient collaboration between the clinical staff and healthcare technology.

More importantly, improvements in Star Ratings depend significantly on how engaged a patient is. For example, measures which are related to medication adherence are almost completely hinged on strong patient engagement that makes it easier for patients to get access to their medications and take them on time. In other words, MA Plans need to deploy efforts that are aimed at implementing holistic strategies to address patient needs.

The Missing Element: Social Determinants of Health

A significant percentage of emergency department utilization has been linked to homelessness. Social isolation has been identified as a key reason for stroke and heart attack. A lot of diabetes-related admissions stem out of food irregularities. These are just a few ways in which the social determinants of health affect health outcomes for patients.

At the end of the day, MA Plans need to consult a mix of different interventions that could help patients manage their own treatments. Healthcare leaders have recognized these links for a long time now, and need to address the social determinants of health. A patient’s education, economic situation, living standards, and many more factors end up influencing a patient’s ability to manage their own care.

Through constant and extensive patient outreach, MA Plans can assess their members’ social needs while ensuring their clinical care plans reflect their social needs. Some patients may be more vulnerable to social determinants than others, which means they would need more assistance from their health plans and providers.

Addressing social determinants of health goes beyond clinical interventions

Plans mostly use health risk assessments (HRAs) and such questionnaires to assess a member’s social needs. While these have been effective in evaluating social needs, these screenings generally have a low completion rate- often 50 percent or less. These screenings to be administered in person, especially for high-risk patients, based on their disease condition or their clinical encounter.

Additionally, MA Plans can also combine demographic, geographic, claims, and clinical data with social assessments to develop predictive models. They can further use these models to stratify member population into different risk categories and develop targeted interventions. They can even leverage machine learning algorithms to improve the accuracy of these models and reach out to high-risk members or refer them to community health workers.

The road ahead 

The underlying growth of Medicare Advantage is definitely good news for value-based care, but as innovation around social determinants of health continues, MA plans need to keep abreast of the non-clinical needs of their patients and continue to coordinate efforts. Regardless of the path they choose, MA plans must begin investing in their capabilities to address the social determinants of health and delivering a holistic experience to their patients to improve their Star Ratings. In the winner-take-all healthcare market of the future, passivity is not an option.