Health Plans Counter Uncertainty by Optimizing Quality and Associated Revenue | Geneia

Health Plans: Counter Uncertainty by Optimizing Quality and Associated Revenue

June 13, 2017
Heather Lavoie, Chief Strategy Officer

Undoubtedly, health plans are operating in uncertain times.

As I write this blog, leaders in the U.S. Senate are working to create an alternative to the Affordable Care Act, one that can earn support from Medicaid-expansion states, the House of Representatives and the President. Most pundits think the odds of this happening in time to have certainty for pricing and managing open enrollment for 2018 are only marginally better than winning the Powerball jackpot, roughly one in 292 million.


Contemporaneously, health plans that participate in the ACA exchanges are in the midst of filing their rate requests for 2018. If the headlines are any indication, significant premium increases will be the norm. A sampling of recent headlines includes:

Likewise, uncertainty was a theme at last week’s AHIP Institute & Expo 2017 in Austin. Sessions with titles like Lessons Learned from the ACA and the Path Forward, The Changing HSA Landscape, and The Health Insurer of the Future: Thriving Amid Uncertainty were well-attended as health plan leaders continue to seek solutions to the mix of challenges to running a successful plan in today’s ever-evolving business environment.

The savviest of health plan executives know they need to optimize the revenue and minimize the expense drivers that are largely under their control, especially in uncertain times. I believe that’s why so many AHIP attendees were excited to read Geneia’s case study about a health plan that used advanced analytics to close care gaps, attain a four-star Medicare rating and rightly earn its share of $3 billion in federal bonus payments.  

I encourage you to download our Medicare Star ratings case study, but in the meantime, let me preview the plan’s results. 

Not only has the health plan repeated its success by achieving a Medicare Star rating of four or more each year since it implemented Geneia’s advanced analytics solution and earning quality bonus payments, but it has also cost-effectively:

  • Reduced reliance on third-party vendors
  • Improved efficiency in data capture
  • Streamlined the process for identification and closure of care gaps
  • Improved coordination across care team members and the practices

In the words of the health plan’s senior vice president of government programs, “Through our use of Geneia’s Theon® advanced analytics platform, our health plan was able to effectively and efficiently conduct population health analysis, measure performance against benchmarks, develop an improvement strategy, and execute a comprehensive and coordinated outreach and intervention plan that resulted in our achievement of a four-star rating for our HMO and PPO products. The platform is also supporting our efforts to achieve a five-star rating.”

Given the high likelihood that uncertain times will continue, I believe it’s imperative that health plan leaders optimize quality revenue by improving Medicare Star ratings and HEDIS® scores. At Geneia, we help health plans increase quality scores and associated revenue, and have created a number of free resources for health plans, including:

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