On the Road to Payer-Provider Convergence
Market and government forces are driving alignment and convergence of payers and providers
November 20, 2017
Heather Lavoie, Chief Strategy Officer
Earlier this year, I introduced you to Blair, a Medicare stars director at a mid-sized regional health plan and end-user of our Theon® analytics, insights and care management platform. Looking back at nearly five years with the plan, her relentless dedication to improvement and quality initiatives drove their Medicare star rating from three stars to a coveted and continued four-and-a-half stars.
Attaining and maintaining a four-star rating is crucial in today’s competitive landscape as ratings impact federal bonuses and enrollment.
Only plans earning four or better stars qualify for millions of dollars in federal quality-based bonus payments. Last year, the Centers for Medicare and Medicaid Services (CMS) paid more than $3 billion to encourage health plans to develop increasingly better ways to manage their Medicare Advantage (MA) populations. Four-star or better plans receive about $500 per MA member and can use those funds to provide their members with higher quality benefits and services, lowered costs and improved customer service.
A 2013 study by the Journal of the American Medical Association (JAMA) revealed the increase of one star positively correlates to a 9.5-percent boost in enrollment.
Current enrollment data confirms this trend, leading CMS to announce more people than ever will join high-scoring plans. They predict 73 percent of all MA enrollees will be in four- or five-star plans in 2018, an increase from 69 percent in 2017. This means high-scoring plans are gaining market share at the expense of their lower-scoring competitors.
Competition among Medicare Advantage plans has been fierce from the beginning. Make no mistake; it’s only getting tougher as:
With 2018 enrollment in high gear, Blair is more than pleased (and relieved) to have maintained her plan’s prestigious standing of four-and-a-half stars.
In fact, only 44 percent of the insurers offering Medicare Advantage plans achieved a four-star or better rating for 2018 -- a significant decline from 49 percent in 2017.
As a good leader, Blair accredits their success in maintaining a high rating to her dedicated team. She fully understands not only the implication of achieving four-and-a-half stars, but also the level of effort required. And she recognizes that they cannot sit back and coast as it is more difficult than ever to keep up a high rating in the face of shifting cut points and measure weights each year. CMS is continuously pushing the bar higher, which, in turn, drives organizations to deliver more.
Blair’s partnership with Geneia and investment in the Theon® platform has turned out to be critical to their ongoing success. They describe the technology as easy to use and understand -- something that should be common sense but isn’t. Second, it identifies and prioritizes gaps across multiple quality metrics and risk adjustment factors so they can focus their efforts. Third, having a clear line of sight into populations and practices means they can coordinate efforts with their providers and engage them in ways that build collaboration and trust while helping them to deliver higher-quality, cost-controlled services to their members.
The industry is catching on to something Blair has known for years – the Theon® platform helps move the needle on Medicare star ratings. Gartner Research recently named Geneia and the Theon® platform as a top solution for speeding up quality reporting that explicitly helps improve Medicare star ratings in its “Top Ten Pain Points and Solutions for U.S. Healthcare Payer CIOs in Government Programs” report.
The bottom is dropping out of the Medicare Advantage market for average-rated plans. To succeed in this competitive and lucrative market, health plans must embrace a long-term commitment to continuous improvement. Improvement is easier and sustainable when quality teams have access to intuitive and predictive technologies focused on closing gaps and facilitating coordinated care.
Download our case study to learn about the three-step process Blair and other quality directors use to attain and maintain a Medicare star rating of four or more stars with the Theon® analytics and insights platform.
Involving value-based providers builds trust and technology adoption
By the end of this year 85% of all hospital payments will be value-based.