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Your Plan’s Success Is in the Stars. PointClickCare Can Help You Reach Them.

The Medicare population is surpassing all other segments of healthcare. With this increase, there is also more scrutiny on how health plans are paid. While potential members may select their Medicare Advantage plans based on several factors, they primarily use a well-known and easily understandable rating system: Star Ratings. A plan’s Star Rating helps members decide between otherwise comparable plans — similar network, costs, benefits — so your rating can have a direct impact on your health plan’s annual enrollment. Plus, with those with at least 4 stars receiving bonus payments and an improved bottom line, Star Ratings reflect your plan’s overall performance and can influence its compensation.

For reimbursement, plans receive value-based payments. The value of care is the quality-of-care relative to the cost required to deliver it. Success is measured by outcomes, how integrated the care delivery is, and how consistent their care management is with evidence-based care and utility.

Star Ratings for Medicare Advantage plans are based on five different categories:

  • Keeping members healthy: screenings, tests, and vaccines
  • Managing members’ chronic (long-term) conditions
  • Plan responsiveness and care
  • Member complaints, problems getting services, and the number of those who choose to leave the plan
  • Health plan customer service

To improve Star Ratings, health plans can facilitate better care coordination, reduce readmission rates, and cut costs by:

  • Receiving real-time member access and updates from facilities and partners.
  • Be informed of discharge plan or emergency department (ED) visits following a post-acute care stay.
  • Improving the information exchange with provider groups, Accountable Care Organizations (ACOs) and Value Based Providers who are typically scored. There is a gained shared savings based on reduced readmission rates and costly ED visits.

In addition, to support the shift to value-based payments, health plans must look at quality metrics in Medicare Advantage plans and collaborate with at-risk providers to manage major quality drivers and cost of care which include the following:

  • Unnecessary readmissions
  • ED utilization
  • Skilled nursing facility (SNF) length of stay

Obstacles to Providing Five-Star Care

Member growth is important. Separate data silos and fragmented member views can lead to lost opportunities for coordinated care and earlier member engagement. Plans must find ways to collaborate with network providers and engage proactively with members to support improved health outcomes and reduce cost of care. Some of the biggest obstacles to managing members’ care include:

  • Network Management: Payers need to establish and maintain a robust network of healthcare providers, including doctors, hospitals, specialists, and pharmacies. Ensuring that the network is adequate, accessible, and meets quality standards can be a significant administrative task. 
  • Compliance and Regulatory Requirements: Medicare Advantage plans must comply with numerous regulations and guidelines set by the Centers for Medicare & Medicaid Services (CMS). Payers need to navigate complex rules regarding enrollment, claims processing, documentation, reporting, and audits. Keeping up with these requirements and ensuring compliance can be time-consuming and resource intensive. 
  • Risk Adjustment and Reimbursement: Payers must accurately assess the health risks and medical needs of their Medicare Advantage members to determine appropriate reimbursement. This involves capturing comprehensive and accurate data on members’ health conditions, documenting diagnoses, and properly submitting claims for reimbursement. 
  • Financial Management: Medicare Advantage plans operate on a capitated payment model where payers receive a fixed amount per member per month. Managing costs, ensuring proper utilization of services, and accurately forecasting financial performance can be challenging. 

With the right solution, it’s possible to overcome these obstacles and improve your Medicare program, enhance access to care for beneficiaries, and ensure your program’s sustainability while providing quality management of healthcare services.  

The PointClickCare Solution

When you improve the quality-of-care members receive, your Star Ratings will also improve. However, to do that health plans need to be able to identify where members may experience gaps in care due to lag times, improper coding, and lack of visibility to members location and clinical status. This is where real-time data across the continuum of care from PointClickCare can help care managers.

  • Improve member access: View member level updates without having to make phone calls or communicate in other inefficient ways with the facilities or care partners. 
  • Minimize readmission: With real-time access, health plans can better facilitate appropriate discharge planning for members which helps minimize readmission rates or ED visits following a post-acute care stay. 
  • Reduce costs: Information exchange benefits health plan partners such as provider groups, ACOs, and Value Based Providers since they are typically scored and gain shared savings based on reduced readmission rates and costly ED visits.

Interoperability for streamlined health data exchange will allow your health plan to better manage your members’ resources and offer effective engagement at the right time to reduce high ED utilization, support safe transitions in care, and improve member satisfaction. To do this, PointClickCare helps your quality management team:

  • Identify members requiring follow-up care based on HEDIS measures
  • Identify coding and time-sensitive care gaps to improve member care 
  • Leverage real-time notifications to enable proactive intervention 
  • Enable real-time notification to downstream network providers to trigger time-sensitive follow-up care to close care gaps  
  • Send discharge summaries to network providers to support patient engagement for identified follow up care and medication reconciliation Transitions of Care (TRC) HEDIS
  • Use the HEDIS specifications to streamline provider performance monitoring and comprehensive reporting

Charting Your Health Plan’s Path to the Stars

To find a solution that addresses your specific need, explore our care collaboration solutions for health plans.

February 8, 2024