When you can align activities such as prior authorizations, utilization management and operational workflows with regulatory mandates for quality, timeliness, interoperability and reporting, you can improve health plan Star ratings.

By Medecision

When prospective Medicare Advantage program or other plan members do their due diligence, they’re likely to research online and discover Medicare.gov, where the Centers for Medicare & Medicaid (CMS) Star ratings are published.

Based on what they find, what are they likely to determine about your plan’s ability to serve them a positive experience?

The reasons health plans should care about Star ratings go beyond the goal of attracting new enrollees and growing membership. Star ratings directly impact plan revenue. Research by Navigant shows that boosting a plan’s rating from three to four Stars increases revenue between 13.4 and 17.6%. What’s more, Medicare Advantage plans that achieve four Stars or higher earn a 5% quality bonus payment, while those receiving below 3.5 Stars receive no bonus. This means that adding one Star to your rating can increase revenue by $2 per member, per month.

Member Experience and Satisfaction: Are Your Star Ratings In Alignment?

With months left to improve performance and lift 2022 scores, payers can take advantage of CMS’ recent changes to Star ratings, which increase the weighting of CAHPS and other scores that reflect patient experience.

More specifically, CMS deems the following five domains particularly salient for payers to improve experience:

  1. Helping members stay healthy
  2. Managing chronic conditions
  3. Improving member satisfaction
  4. Reducing the number of member complaints
  5. Providing high-quality customer service

Starting in 2023, 57% of the total Star score will depend on how members rank their healthcare experience, based on the idea that a better experience empowers patients to take a more active role in their own health.

Payers will benefit from aligning activities such as prior authorizations, utilization management and operational workflows with regulatory mandates for quality, timeliness, interoperability and reporting to help them improve their health plan Star ratings and other measurements.

Improving Health Plan Star Ratings Must Be Viewed as a Team Effort

Much of a payer’s performance on what CMS identifies as the five key domains depends on the actions of providers. According to actuarial firm Milliman, plans that consistently achieve high Star ratings proactively manage provider relationships. Payers that can find ways to continually give their providers what they need to facilitate better care will typically achieve better ratings. This makes payer-provider shared workflows and procedures around care management, the coordination of care plans, and utilization management areas ripe for improvement.

A Good Place to Start: Prior Authorization

The manual processes around prior authorization (PA) create inefficiencies and delays that have led to serious adverse events for patients, according to the American Medical Association’s PA physician survey. In fact, 34% of those surveyed reported a patient in their care had experienced one of these avoidable events. Adverse events have included a patient’s hospitalization; deterioration in a patient’s condition leading to a life-threatening event; a required intervention to prevent permanent impairment or damage; and/or patient disability, permanent bodily damage and even death.

A full 90% of the physicians surveyed say they believe that, for their patients needing treatments that require PA, the process has a somewhat or significant negative impact on these patients’ outcomes.

Efforts to speed up the process are a key lever for responding effectively to the increased emphasis on patient experience. Automating PA workflows reduces the wait times that can cause the negative impacts that physicians identify. By working with providers to digitally integrate PA requests into standardized processes, payers can further cut the delays that drag down Star ratings.

Take, for example, Piedmont Community Health Plan. In March 2020, Piedmont went live with Aerial, Medecision’s HITRUST CSF-certified SaaS solution, to improve efficiency and automate prior authorization. The plan’s strategy included a proactive clinical integration component, giving providers access to actionable care gap information about their members. In addition to speeding authorization times by 57%, the changes increased provider and patient satisfaction.

The Role of Utilization Management

Utilization management (UM) workflows can be streamlined not just to reduce delays but also to create time in a provider’s day, time that can go toward more activities that positively impact patient experience. And when facilitated by an electronic system, UM is a way to not only manage cost but also ensure quality. Solutions that enable easy access to real-time data allow providers and payers to act promptly on patient issues that can negativelyimpact Star ratings.

Streamlined UM processes reinforced by an interoperable solution can also improve outcomes. Auto approval of routine requests allows care managers to focus their attention on more complex authorizations, such as for high-cost services, drugs or procedures for at-risk members.

Operational Workflows

Optimizing patient-provider workflows has many advantages, including the support of timely clinical decision-making. More generally, in terms of improving health plan Star ratings, payers can benefit from revising workflows to enable prompt solutions to members’ health challenges. Speedier authorizations and referrals contribute to that and help members feel valued. A survey conducted by Forrester shows that consumer loyalty—and presumably the positive feeling that influences higher scores—improves in members who feel appreciated by their plan. Sixty-four percent of customers who indicated they felt respected by their health plan said they planned to stay with their plan and 84% said they would advocate for the brand.

Stars Are Making Competition More Fierce

Health plans lagging on Star ratings are increasingly falling behind in other critical areas, according to a PricewaterhouseCoopers report: “Top performing plans are raising Star benchmarks each year and placing downward pressure on product pricing,” the authors explain. A particularly relevant hurdle, they say, is “access to accurate and timely data from provider networks [which] remains difficult to extract.”

Payers that invest resources in optimizing working relationships and interoperability with their providers stand to improve the workflows and processes that support a positive member experience and ultimately better Star ratings.

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