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Medicare Advantage evolving Star Ratings criteria: how technology can bridge the post-acute gap

This year, over one-third of Medicare beneficiaries are enrolled in Medicare Advantage (MA), and that percentage will only continue to increase. For insurers offering MA plans, the challenge is keeping up with evolving star rating criteria as this member population grows. Just because a plan has achieved a 4-, 4.5-, or 5-points star rating in past years doesn’t mean that it will automatically achieve that rating again. Each year the quality criteria gain depth, making it more challenging for plans to perform well enough to receive bonus payments.

Post-acute care coordination has not traditionally been a focus for Medicare, but the shift of the healthcare system from fee-for-service to value-based reimbursement is now placing greater emphasis on the post-acute space and pushing plans to bridge the gap between acute and post-acute. That’s why many forward-thinking plans are investing in data-driven technology platforms like CarePort Health that are specifically designed to help them improve the quality of care and streamline member transitions across the continuum. In talking to insurers that offer MA plans, we’ve identified four main use cases for this technology.

Use Case #1: Care Management

Effective care management, a core requirement of MA, means that plans need to have a holistic view of their members’ conditions, as well as a thorough understanding of the care their members are receiving in both acute and post-acute settings. In the absence of tools to help them assess how well post-acute facilities are meeting their members’ needs, plans have resorted to sending clinical staff out to visit SNFs and other post-acute facilities. In-person site visits take significant time, effort, and dollars, and don’t consistently yield actionable information.

Care management technology can give plans a much more complete picture while increasing the efficiency of care management efforts and reducing associated costs, including:

  • More targeted actions based on personalized, individual clinical needs
  • Increased visibility into unnecessary length of stay and a decrease in readmissions
  • Better support during care transitions, after-care, and care coordination

CarePort Guide, which facilitates informed selection of post-acute care, has the added benefit of improving member engagement, since it’s a tool that can be used by patients, not just providers.

Use Case # 2: Quality Management for Stars Reporting

The two main reasons that plans get marked down on quality measures are related to data analytics capabilities:

  1. They don’t have any data other than claims related data to show that their member health is improving, or
  2. The data they do have is insufficient to demonstrate the plan is meeting quality standards

Plans need information about members in all care settings, which adds to the challenge. Not only do they need to know how a member is doing during an acute episode in the hospital, but they also need to be able to track that member’s progress post-discharge as they transition to a SNF or home health. If the member is then readmitted to the hospital or moves from one post-acute setting to another, the plan also needs to be notified—not after the fact, but in real time as events occur. Administrative claims data is retrospective and thus inadequate.

CarePort Connect, on the other hand, provides current, accurate patient data at both the individual and populations levels. As a result, plans see these benefits:

  • Gain increased awareness of gaps in care following acute care length of stay
  • Access sufficient clinical data to render quality score measurements and continually adjust priority/focus throughout the year
  • Increase standard SNF data collections and reduce need for source validation

Use Case #3: Post-Acute Provider Assessment

As part of their population health strategies, plans are not only looking at their member populations, but also at their provider populations. For MA, they need to understand which disease states align better with which special needs post-acute facilities so that their members are matched with the provider that can achieve the best possible health outcome.

Part of the provider assessment process is looking at how post-acute facilities perform on standard benchmarks such as length of stay and readmissions. CarePort’s technology replaces provider self-reporting with objective data. For example, plans not only receive information about the average length of stay for patients with certain conditions or recovering from certain surgeries, but also much-needed context such as how a given facility is performing against the average or against other facilities.

Use Case #4: Provider Network Creation and Contracting

Building on the previous use case, with the contextual information provided through CarePort Insight, MA plans are able to create preferred networks of specific disease state (e.g., cardiac care, total joint) and risk-adjusted post-acute providers. In fact, one of the overall trends in 2018 in the post-acute space is increased specialization among SNFs. Research has shown that greater specialization is tied to both improved outcomes and less variation in care quality.

Once plans have identified the high-performing SNFs they want in their networks, they can set up value-based contracts with them so that the SNFs are also reaping rewards for improving outcomes.

As the expectations for MA plans get higher and higher, insurers need to think outside the box and find new ways to deliver results. CarePort’s innovative technology provides the real-time data, context, and support needed to navigate the evolving star ratings system.

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