“Why are payers still struggling with a lot of complicated tasks? What holds the key to solving their problems?”
Would you be surprised if the answer to the above question is patients themselves?
Although payers are fairly young in the US healthcare dynamics, they have become a substantial element in the transforming value-based healthcare. Considering the current pace with which we are evolving in terms of delivering quality care, it would become quite difficult to realize the dream of efficient healthcare if we leave payers behind.
Often the things that are missing end up making the most difference, and so is the case with providing patient-centric care. We may put in all our efforts into improving the patients’ health, but finding the missing piece of information for payers is the biggest challenge of it all. And then there are reviews, audits, HEDIS measures, and most of all, STAR Ratings.
Why are STAR Ratings such big shots for everyone?
CMS STAR Ratings directly impact the revenue for Medicare Advantage (MA) plans. Higher ratings bring better quality bonus payments (QBP) for payers, and on the other hand, lower ratings bring penalties and in the worst case, termination.
Going forward, the STAR Rating evaluation will be more crucial for not just the payer organizations but also for the providers. CMS is aiming for saving $2.2 billion over ten years for Medicare, something that would be in the line of advancing the goal of accountability, engagement, integrity, competition, and quality.
The complicated web of data for payers
About 60% of the US population suffers from at least one chronic disease, and many of them fail to adhere to their treatment regimes. A great number of patients are not able to follow-up on their physicians after an episode or a surgery effectively. There are many such cases and they account for higher admissions, readmission, ED visits, and many more.
The biggest challenge is that the data systems in healthcare do not communicate, and in turn, obstruct the connectivity between payers and providers. Be it patient charts, lab results, physician notes— all of these have crucial information to provide, but before that, they have to be brought together so that they could provide a clear picture of where the improvement is required.
The guide to capturing the fifth star with effective care management
Care management and payer performance go hand in hand. We cannot deliver true patient-centric care if payers are not able to get their hands on the most crucial data elements to act as an auditor. A while back, I came across a survey by McKinsey and Company which stated that only 21% of Medicare Advantage plan enrollees knew their plan’s STAR Rating.
Payers need to collaborate with physicians to build a mechanism for them to support patient-health initiatives at every step. For scoring a higher STAR Rating, they need to ensure that their patients receive appropriate care and they are aware of what is happening to them. Here are the four key steps in developing a better patient-centric environment and ensuring higher returns on investment:
- Not just plan your data but also your approach: It takes the collaboration of both providers and payers to improve the health of patients in their network and deliver better financial outcomes. Identify the quality measurements that are crucial for reporting purposes and target those with the most potential impact. Payers need to identify their ability and assess each measure corresponding to their ability and understand how it will affect their summary score. And to understand their performance, they need data not just from traditional EHRs or claims records, but from other sources such as practice management systems (PMS), financial systems, ADT feeds, pharmacy, and many more.
- Engage your providers at each step: The providers can help in many ways to improve the overall quality scores. When their processes are streamlined, indirectly the processes of payers can be improved. Poor adherence to physician treatment plans and care plans result in reduced STAR Ratings and overall performance. With empowered and connected physicians and care teams, payers would be able to track the performance of each member on every reporting measure. Once they ensure a streamlined information management on-the-fly, they can help in reducing physician burnout, patient fall-rate, erroneous reimbursements, and a lot of other factors.
- Pinpoint at the at-risk and high-risk patients: The most important step is to identify the patient population and segregate them based on their risk scores and other relevant factors to know which patients require the most care. Factors such as Length of Stay (LOS), hospital readmissions per 1,000, ED visits, patient satisfaction scores, among many contribute to the performance of providers and payers need to understand the actual number to these measures— and that too at the point of care.
- Bring automation to enhance the quality of each step: The main culprit behind the sorrows of payers is the redundant task of acquiring member charts from providers— a process that demands hours of manual labor. Simply relying on such manually-intensive processes cannot enable payers to dive deep into the root of the care gaps to ensure coordinated care across the network. The best possible way to simplify the process is to enhance the connectivity among multiple health systems through automation. This would empower payers to map member activities along with network utilization to highlight the gaps in care and reduce the turnaround time to a matter of few minutes.
The road ahead
Risk adjustment programs are designed to financially reward payers with higher medical loss ratios (MLRs) to ensure that they enroll high-risk beneficiaries. Payers are an integral element in understanding different segments of healthcare as they direct the bulk of healthcare dollars. We need evolving partnerships. We, as members of changing healthcare, need payers and providers to work together, and we need payers, providers, and leaders to come together for a greater cause to delivering the care every patient deserves.
This blog has originally been authored by Abhinav Shashank.
