For medical insurance payers, reaching success in Medicare Benefit (MA) hinges on the Stars. Larger Star Rankings not solely drive enrollment and retention (with 74% of MA-PD members presently enrolled in contracts boasting 4-stars or increased) but in addition contribute to elevated revenues by means of greater bonuses and rebates (with an anticipated improve in bonus funds totaling $13.8 billion in MY2024). The problem? Sustaining excessive Star Rankings or bettering upon present rankings will get more and more troublesome over time.
Yearly, alterations to the Star Rankings methodology introduce a recent spherical of changes for Medicare Benefit plans to navigate. 2024 was no completely different. CMS made important modifications, together with revising minimize level calculations utilizing the Tukey Outlier technique, amongst others. Subsequently, solely 31 MA plans attained a 5-Star Score and the common score declined from 4.14 to 4.04 – a significant trigger for concern as competitors intensifies within the MA market.
Nevertheless it’s not all dangerous information. Even because the Star Rankings system modifications in sync with the evolving healthcare panorama, MA plans can enhance their rankings by elevating member satisfaction.
Why member expertise issues now greater than ever
Closely weighted CAHPS measures proceed to affect Star Rankings yr after yr. They prioritize member expertise by assessing the well being plan’s customer support capabilities in addition to ease of accessing care promptly and when wanted. Moreover, CMS’s newest revisions to the Star Rankings system within the 2023 Ultimate Rule emphasize member expertise much more. The revisions purpose to prioritize well being fairness and handle social determinants of well being (SDOH) by introducing a brand new Well being Fairness Index (HEI). The index is designed to incentivize plans that serve and obtain higher outcomes amongst bigger low-income, dual-eligible, and disabled populations. For plans, successfully reaching these cohorts will likely be key to success.
Whereas the HEI incentives are set to affect Star Rankings beginning in 2027, the calculations will likely be primarily based on well being plan knowledge between 2024 and 2026. This implies plans should start to plot methods now, in 2024, specializing in the identification of care gaps and implementation of proactive engagement efforts.
Main roadblocks to elevating the member expertise
The fact is reaching a superior member expertise is a difficult journey fraught with obstacles. MA plans usually face useful resource and functionality constraints as they attempt to fulfill CMS compliance necessities whereas concurrently enhancing member engagement and satisfaction. Two different components pose important challenges:
- Overemphasis on compliance: Whereas plans understandably prioritize compliance to take care of operational integrity and keep away from contract termination, the extreme give attention to compliance can inadvertently end in a tunnel imaginative and prescient strategy – putting in depth guardrails, diluting buyer expertise, and negatively impacting the member expertise – consequently reducing their Star Score.
- Outdated engagement methods: Failure to successfully take heed to their members and handle important components of member expertise and care supply additionally results in less-than-ideal outcomes for plans. Lack of personalization, restricted communication channels, reactive help methods, and disjointed experiences – all hamper significant interplay, resulting in disengagement, dissatisfaction, and potential disenrollment on the a part of members.
Getting member expertise proper: 4 methods
Listed here are 4 methods geared toward sustaining a pointy give attention to closing care gaps whereas concurrently adopting a proactive strategy to extend profit utilization, driving enhanced belief, member satisfaction, and loyalty.
- Allow data-driven identification of care gaps: Make the most of superior knowledge analytics to establish care gaps – resembling missed preventive screenings, remedy adherence points, or gaps in continual illness administration – and tailor interventions. Incorporating Social Determinants of Well being (SDOH) knowledge into predictive fashions is usually a game-changer in bettering member engagement and communication effectiveness. Answering questions resembling, “Does the member have entry to transportation?”, “What does their help system seem like?”, and “Are they financially secure?”, may help you higher establish care gaps, and design extra customized and impactful campaigns.
- Drive holistic engagement throughout the member journey: Interact and help members throughout their well being journey to ship a seamless and constructive expertise whereas selling higher well being outcomes. This includes serving to members perceive the enrollment course of and their advantages, selling preventive care and wellness, and offering care coordination for members with continual situations. Harness superior knowledge analytics to phase your members primarily based on their well being situations, danger components, and utilization patterns, to prioritize outreach efforts. Direct these calls to skilled and specialised advocates who possess empathetic strategies and disease-specific data to optimize utilization and effectiveness.
- Make the most of AI for advocate empowerment: Healthcare advocates usually spend inordinately massive quantities of time navigating a number of methods to collect the suitable info to greatest help every member. Deploy AI-driven data bases to push the suitable info to your advocates on the proper time, not solely making their lives simpler, but in addition bettering effectivity and tailoring experiences. Offering advocates with real-time buyer insights, alerts, advantages info, and customized suggestions allows them to achieve a greater understanding of your members’ present and future wants, swiftly handle points, and proactively counsel optimum options.
- Allow scalable recruitment automation: Deploy AI algorithms to shortly analyze massive volumes of applicant knowledge, together with resumes, utility kinds, and assessments, and establish prime candidates primarily based on predefined standards resembling abilities, {qualifications}, and cultural match. By leveraging adaptive studying strategies, AI may also dynamically modify coaching content material and supply strategies to go well with the distinctive wants and preferences of every learner, resulting in simpler studying outcomes. Tailoring coaching applications to the particular wants of every worker allows fast mastery of job-related abilities and data, in the end resulting in improved key efficiency indicators (KPIs) resembling Buyer Satisfaction (CSAT), Common Dealing with Time (AHT), and attrition charges.
Begin early for a profitable yr’s finish
In an election yr, the place healthcare affordability and entry take middle stage, it’s much more necessary for MA plans to accentuate their give attention to member expertise early within the yr. Prioritizing member expertise now, versus mid-year, can go a good distance in guaranteeing quite a few strategic, monetary, and operational advantages. From guaranteeing election promoting doesn’t negatively affect Annual Enrollment/Open Enrollment (AE/OE) methods and timelines to driving member satisfaction and bettering Star Rankings.
By 2030, practically half of the MA-eligible inhabitants is projected to be aged 75 or older, in comparison with roughly 40 % presently. An important query is: will MA plans be capable to quickly adapt to the altering Stars methodology to drive member and plan success? These plans that combine digital applied sciences like AI, automation, and analytics with empathetic human abilities, adaptable workforce methods, and seamless omnichannel engagement will take the lead within the trade.
Picture credit score: marchmeena29, Getty Pictures
Becky Watkins is the Senior Vice President, Consumer Options, at ResultsCX and is chargeable for constructing the corporate’s built-in go-to-market technique for enterprise improvement and serving because the senior level of contact for all purchasers. Becky brings over 30 years of expertise to ResultsCX, with expertise from the BPO trade, together with an in depth 10 years devoted to healthcare solutioning and outsourcing.