By Rachael Jones and Brenda Cappellini, R.N., CMCN
This year, 77% of those enrolled in Medicare Advantage plans with drug coverage are in plans with 4 or more stars, up from 69% in 2017, a Centers for Medicare & Medicaid Services (CMS) analysis shows. It’s an indicator of the quality of care these plans provide—and the level of competition that exists for member recruitment.
Medicare Advantage is the fastest-growing health insurance market, with enrollment doubling from 2011 to 2020. The number of Medicare contracts increased 10% from 2019 to 2020, mostly driven by large national payers expanding into new markets. This raises the stakes for existing plans: Those that don’t earn 4 stars or more will likely find it difficult to attract new members. They will also miss out on the 5% bonus paid to plans that achieve ratings of 4 stars or higher.
In 2019, The Health Plan of West Virginia, Inc. (The Health Plan), one of the largest locally managed care organizations in West Virginia with more than 200,000 covered lives, began a journey to move from 3.5-star to 4-star or higher performance. The key to this effort: using data analytics to identify the right strategies for improvement and to provide support to close gaps in care.
Why Analytic Tools Give Plans an Edge
For 2021, more Medicare Advantage plans earned a coveted 5-star rating, CMS’ highest rating. However, while enrollment in plans earning 4 or more stars increased, the overall percentage of plans earning 4 or more stars decreased by 4%. Those most likely to receive 4 or more stars are Medicare Advantage plans with prescription drug coverage that have operated for 10 years or more. The reason: These plans are more likely to have seamless and integrated processes in place to navigate changes to the program, especially the increased weight of administrative measures and measures tied to member satisfaction.
For The Health Plan, which serves seniors in the Appalachian region, the challenges of managing population health are magnified by the health challenges residents face.
West Virginia is the only state that is completely located in the Appalachian region, which is marked by high rates of poverty and dramatic disparities in health outcomes. There are fewer health professionals per 100,000 members when compared with the country as a whole, one analysis shows, and rates of mortality are higher for seven of the leading causes of death. The pandemic likely will raise mortality rates, particularly for diseases of despair such as overdose, suicide and liver disease, which were already 36% higher for the Appalachian region in 2018 than for the rest of the United States.
Since 2015, The Health Plan has partnered with Cotiviti, a healthcare data analytics company, to measure and report compliance with HEDIS measures for its Medicare Advantage population. Using Cotiviti’s analytics capabilities, The Health Plan has been able to drill down to member-level claim detail to determine where opportunities for improvement exist and which members and providers to target to optimize use of resources, reduce expenses and enhance outcomes and the member experience.
When working to move from 3.5-star to 4-star performance, The Health Plan faced challenges related to its small population size—around 16,000 SecureCare HMO and SecureCare PPO Medicare Advantage members—combined with the wide geographic spread between members and providers. And with CMS doubling the weight of patient experience metrics under Medicare Advantage so that they comprise 32% of the Star Rating for the 2021 plan year, The Health Plan needed more advanced insight to improve performance.
To surmount these hurdles, in 2019 The Health Plan became an early user of Cotiviti’s Star Navigator, a quality improvement tool that uses data to determine the most direct path to Star Ratings improvement.
Supercharging Performance Insight
The Health Plan collected Star Ratings data and paired it with social determinants of health data from the organization’s population health management platform. Then, The Health Plan leveraged modeling tools to assess the impact of each Star measure on its overall score and identify strategies for improvement that would position the plan for a 4-star rating.
Monthly reports identified where gaps in care existed for specific members, such as mammography screenings or diabetic retinal exams. With this information in hand, The Health Plan could then evaluate the best approaches for closing care gaps. During the pandemic, the organization relied on the data not just to pinpoint which members needed services, but also to map the providers that could provide those services locally or within a comfortable driving distance. The population health team validated instances where care gaps were closed and tracked progress carefully, adjusting their approach, as needed.
This data proved crucial during the pandemic, when members were likely to delay needed care due to concerns about contracting the coronavirus during a healthcare visit. In the summer of 2020, The Health Plan ran reports to see which members had multiple gaps in care, such as screenings for breast cancer, cervical cancer or colon cancer or comprehensive diabetes care measures like diabetic eye exams and kidney disease monitoring. From there, population health nurses contacted members to gauge their level of comfort in seeing a physician one on one and—where coronavirus fears held them back—suggest alternatives for care, such as virtual visits. The Health Plan also mailed screening kits to members, such as at-home screening kits for colorectal cancer, to make it easy for members to get the health and wellness services they needed.
The Health Plan tracked its efforts with customized dashboards. When the organization neared its goal of a 4-star rating, the Star Navigator tool alerted leaders to the plan’s progress. This enabled The Health Plan to focus on quick wins and action steps that offered the highest return on investment, putting the plan closer to its goal.
A Data-Based Foundation for Success
The Health Plan’s experience in using data analytics to achieve a higher rating amid the pandemic provides lessons learned that could help other plans bolster their results, even as Star Ratings criteria change.
- Use predictive models to inform which members you reach out to—and how. For example, in rural Appalachia, research shows that older adults—those 85 and older—prefer to be contacted by phone. Use member surveys to gain an understanding of the member’s preferred methods for communication. Make sure they indicate the time of day at which they are most likely to be available as well.
2. Hire a full-time Star Ratings quality manager. As monthly reports point to gaps in care or services, appointing a single person to review the recommendations, prioritize opportunities and lead actions that could drive improvement strengthens efficiency. It also helps secure engagement from key stakeholders by giving them a single contact to turn to with advice and guidance.
3. Track measures in one place. The organization cannot gain a sense of the big picture if each team tracks performance differently or if teams are separated by information silos. Achieving 4-star or higher status requires participation from employees across the health plan, not a single team.
4. Create a strong interdepartmental team to review progress. At The Health Plan, a Stars Committee meets monthly to share ideas for improvement, collaborate on initiatives informed by data, and develop programs that help fuel continued Star Rating wins.
5. Focus on the top-weighted measures first. Evaluate where the low-hanging fruits lie and create a subcommittee to oversee priority action steps, assess progress and recommend alternate paths to value, when needed.
6. Build care gap reports for providers. At The Health Plan, these reports will soon be available through self-service provider portals. Providing actionable data around ways to close gaps in care empowers physicians and care teams to improve performance under value-based contracts. It also establishes a basis for higher degrees of collaboration and trust.
By relying on advanced analytics to inform their approach to collaboration and member engagement, health plans can more effectively set themselves up for Star Ratings success while elevating the member experience—a win-win for all.
Rachael Jones is Senior Vice President of Performance Analytics and Quality for Cotiviti. Brenda Cappellini, RN, CMCN, is Assistant Vice President, Population Health for The Health Plan.
