Optimizing Quality with Proactive Outreach

Improving Star measures for Medicare Advantage plans

August 4, 2022
Senior Medical Director, Accordant Health Services

Quality ratings have a huge effect on the competitive and financial success of Medicare Advantage plans. The Centers for Medicare & Medicaid Services (CMS) Star Rating system brings transparency to consumers choosing plans, making it easy to select plans that have high ratings. But in addition to the consumer decisions that play into enrollment counts, Star ratings also matter for a plan’s financials and future.

Even incremental improvements can have a big impact: bonuses can bring in an extra 5% to 10% a year per member. A four-star plan with 1 million members could potentially bring in ~$500 million in bonuses alone.https://khn.org/news/medicare-plans-score-higher-ratings-and-millions-in-bonuses Payment levels and rebates for plans with four or more stars can be quite substantial, and because rebates are used to subsidize premiums, reduce copayments and deductibles or finance enhanced benefits (such as vision and dental), plans that get higher rebates have an advantage in attracting new enrollees.

When prioritizing areas for improvement, plans can take different approaches, choosing to tackle some initiatives in-house and others externally, working with a vendor partner. As the list of measures and cut points is updated each year, plans are tasked with reviewing the data and making incremental changes to strategy. Because member populations can differ significantly by location and makeup, there is no one-size-fits-all solution. But we have found that proactive outreach is a configurable solution that can be tailored to meet many plans’ needs.

Defining Proactive Outreach

The idea of proactive outreach goes beyond phone calls and letters to members with a gap in care. It is the idea of motivating effective change with digital and pharmacist-directed interventions, which leads to improving clinical adherence measures. Many members in these populations already have an ongoing trusted relationship with their pharmacists – pharmacists are in the top 4 of most trusted professions in a recent Gallup poll – and we leverage those relationships to power this program.https://www.drugtopics.com/view/pharmacists-top-most-trusted-professions-gallup-poll

Letters and phone calls are two often-used communication methods, but there are other ways to reach members. Text messages, mobile applications and in-person pharmacy visits can also be used to facilitate engagement and reach members using the methods they prefer. It’s also important to clarify that outreach should have logic behind it, targeting the highest gap closure. Predictive analytics enable the right interventions, with the right channels, at the right time so that members can make connections sooner to help manage their conditions and treatment.

With our quality solutions geared toward Stars improvements, we’ve changed the way we communicate with members. We’ve made a significant investment to continue to improve this dynamic and support the best environment for our pharmacists to be successful in overseeing prescription fills and also to provide more counseling for members with chronic conditions and provide members with proactive, ongoing support.

The role of the pharmacist in closing gaps in care

With our quality solutions, pharmacists can provide 1:1 interventions, counseling and coaching during in-person visits and by phone. We have made significant changes in the way that our pharmacists communicate with members to ensure they can practice at the top of their license and provide counseling to members. They can help get to root causes of gaps in care, and help the member close those gaps – looping in the provider if appropriate. We have observed a 75% engagement rate because pharmacists feel empowered to be more proactive and effective.Source 75%: CVS Health Analytics, 2020. Pilot results from study of two large health plan client populations; 09/24/19 ‐ 02/22/20 and 12/04/19 ‐ 02/22/20. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. Client‐specific modeling available upon request. P1004270320.

Part of the success of these proactive outreach results is because plans are able to customize the focus areas, whether it be a breast cancer screening or diabetes medication adherence. Because each population is different, plans can customize their approach and member needs.

Increasing star ratings takes time and effort but the gains can be significant. Working with vendor partners, or bringing additional partners to the table, can take some of the guesswork out of improving ratings.

The financial benefits of even small improvements can be significant, from reimbursement rates to bonuses and additional enrollment time through the year. And having a higher rating means that when compared to other options on the Medicare Plan Finder website, consumers will see your plan more favorably too.

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August 4, 2022
Senior Medical Director, Accordant Health Services