Latest / Becker’s Payer Issues Podcast / Boosting Star Ratings: The Key to Health Plan Success

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Boosting Star Ratings: The Key to Health Plan Success · Becker’s Payer Issues Podcast

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  Hi, everyone. This is Lucas Voss with Becker's
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  Healthcare. Thanks so much for tuning in to
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  the Becker's Payer Issues podcast series.
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  Today, we're going to be talking about boosting
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  star ratings, the key to health plan
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  success.
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  And joining me for today's discussion, I'm very
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  excited to have her, Whitney Eubanks, VP product
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  management at PointClickCare.
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  Whitney, thanks so much for being here today.
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  It's great to have you. Thanks for having
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  me. Yeah. Excited to be here and just
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  to discuss this topic.
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  Absolutely. Could you just introduce yourself to your
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  audience to our audience really quickly?
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  Sure. Yeah. So like you mentioned, vice president
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  of product management for PointClickCare's
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  acute and payer business where we're really focused
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  on building out the country's largest real time
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  care coordination network.
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  I've been at PointClickCare for a few years
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  now. I've spent nearly twenty years in product
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  marketing and product management roles, primarily in health
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  care technology.
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  Then Then a lot of my time working
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  with health plans and pharmacy benefit managers
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  through the course of my career. So this
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  is a space and a topic near and
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  dear to my heart.
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  And it's great to have you. And we
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  are talking about
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  boosting star ratings. But before we're doing that,
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  we have to talk about
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  why we have to boost them
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  and the recent drop in star ratings for
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  major health plans.
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  What's at stake
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  if don't they don't improve,
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  and why are we seeing those drops?
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  Yeah. Yeah. It's a good question. I mean,
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  the drops are pretty dramatic. So just last
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  year, eighty percent of Medicare Advantage enrollees were
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  in four star or better plans,
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  but now that number is down to sixty
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  four percent.
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  Wow.
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  And and five star plan enrollment fell off
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  a cliff. It went from twenty two percent
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  down to two percent. So, yeah, the question
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  is what what's going on here?
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  And really, it's two main things. First, CMS
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  changed
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  how they calculated the cut points. Essentially,
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  they removed the lowest performing plans from the
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  equation,
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  which Mhmm. Raise the bar really across the
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  board, and I think caught a lot of
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  plans a bit off guard.
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  But the second thing is that the competition
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  is just getting tougher. So if you're not
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  improving year over year, you're actually falling behind.
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  But in terms of of impact and what's
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  at stake, there's real money on the line
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  here. So if you are a plan and
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  you drop below four stars, you're losing
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  quality bonus payments, which can impact the bottom
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  line and really hurt the ability to attract
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  new members as well.
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  I was gonna say, I mean, at the
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  end of the day,
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  name of the game is bottom line for
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  most folks, I would assume. What's the impact
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  on
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  a health plan's
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  bottom line? And then in turn, what are
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  some of those ripple effects that you're seeing
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  that impact patient care and also long term
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  sustainability?
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  Yeah. I mean, in in short, it's a
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  big deal. So a drop from four and
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  a half to three and a half stars
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  can slash a plan's operating income by up
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  to 40%.
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  Mhmm. And when revenue drops, the plans start
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  cutting back on extra benefits that make them
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  competitive in the first place. So you've kinda
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  got this vicious cycle going on. Lower ratings
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  means fewer members,
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  which means less revenue to invest in quality
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  care, and eventually that starts to impact
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  patient outcomes, patient experience, and the plans are
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  are kind of stuck playing catch up.
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  And then you're having to deal with what
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  you've mentioned earlier too. There's more and more
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  competition. Right? So if you're not improving,
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  you're going to be even further caught into
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  that cycle, and it keeps going and going
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  and going.
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  So what steps can health plans take right
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  now to turn declining scores around and and
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  stay ahead in an increasingly competitive landscape?
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  I think most importantly, it's understanding where CMS
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  is going.
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  So they're shifting weight from patient experience to
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  clinical outcomes, and real time is the name
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  of the game. Your best chance to optimize
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  outcomes is actually during some kind of health
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  inflection point. So especially those transitions right after
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  an emergency department or an inpatient encounter.
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  That's when patients are the most vulnerable, but
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  they're also the most receptive to behavior change
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  or
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  taking action on next steps that are required,
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  after those encounters.
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  So that means that measures like TRC, transitions
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  of care, the follow-up after ED visit for
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  high risk patients or what they call FMC,
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  and plan all cause readmissions, PCR, which is
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  actually triple weighted now. Those measures are front
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  and center in star ratings just to to
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  give a couple examples.
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  And if you focus on transitions
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  and and really improving that experience and reducing
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  readmissions around those critical points, you may also
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  boost your patient satisfaction as well, which, of
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  course, can have an indirect impact on CAHPS
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  surveys.
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  And then in turn, like you said, that's
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  what's going to get those stars up. In
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  terms of how we're doing this,
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  how can real time data access and exchange
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  enhanced care coordination between health plans, hospitals, and
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  providers
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  lead to more of a boost in those
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  star ratings and and getting them up?
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  Yeah. It's a game changer. I mean, if
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  you're still using claims data to manage care,
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  you're you're already way too late. Real time
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  clinical data helps care teams act fast right
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  when the patient needs that care the most.
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  Actually, my mother-in-law works as a care manager
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  at a health plan, and she's even, had
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  responsibility
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  for training these care teams. And she's shared
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  with me so many stories
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  about some of the challenges that that those
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  roles face. But what really stuck out to
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  me is,
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  her saying, you know, I have precious few
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  moments with a member. And if I am
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  spending that time
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  asking for information about what happened when you
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  were in the hospital, what were your discharge
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  instructions, then I'm not spending
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  ultimately will improve star ratings, if you're not
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  using that precious time talking about how we
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  can help guide their next steps of care.
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  And it's very difficult to get the outcomes
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  that we all want those outcomes that ultimately
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  will improve star ratings if you're not using
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  that precious time
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  very wisely.
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  So, you know, from my perspective, this is
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  a very solvable problem with real time encounter
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  alerts, real time clinical data. Care teams can
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  jump in immediately after a hospitalization.
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  They can work to close care gaps. They
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  can coordinate with providers or automate
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  intelligence heading over to providers who need to
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  do follow-up care and ultimately reduce readmissions.
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  But at the end of the day, it
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  really just comes down to being proactive
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  instead of reactive, which is exactly what CMS
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  is rewarding now. Yeah. And
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  like you've just talked about, it comes back
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  to full circle what we talked about earlier.
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  Right? It all has ripple effects on patient
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  care. On that long term sustainability that we
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  talked about. It's a very important piece. Whitney,
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  thanks so much for taking the time today
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  and and walking us through this. This is
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  an important topic, and and I'm glad you
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  you spent some time with us today.
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  Yes. Thank you so much for having me.
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  Absolutely. And we also want to thank our
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  podcast sponsor, PointClickCare.
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  You can tune into more podcasts from Becker's
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  Healthcare by visiting our podcast page at beckerspayer.com.