Every year the Centers for Medicare & Medicaid Services (CMS) releases the Star Ratings for Medicare Advantage plans. The Medicare Star Rating System was developed to help Medicare consumers compare Medicare Advantage plans based on quality and performance.
Star ratings are determined from a set of quality performance ratings developed by the National Committee for Quality Assurance (NCQA) and CMS. Medicare Advantage plans are rated on how well they perform in 5 categories based on the five-star rating scale, with five being the highest score.
Plans are given an overall rating based on their performance in five categories.
- Staying healthy (screenings, tests, and vaccines)
- Managing chronic (long-term) conditions (such as diabetes, high blood pressure, arthritis, and osteoporosis)
- Plan responsiveness and care (member experiences getting care, prescription medications, etc.)
- Member complaints, problems getting services, and choosing to leave the plan
- Health plan customer service (such as processing appeals, new enrollments, and accessibility
Plans are rated in each individual category, and Medicare also assigns plans one overall star rating to summarize the plan’s overall performance. These 5 categories fall under one of these two “buckets” for quality and performance measures that CMS may use to determine the star rating for a Medicare Advantage plan: Quality and performance measures related to the plan or plan provider and Quality and performance measures related to health services.
Fortunately, for payers looking to improve star quality ratings, the medical management platform they use could help to support efforts to improve ratings across the five categories. Specifically, with HELIOS in mind, there is the opportunity for care team collaboration to better provide value-based care experiences and health outcomes, as well as increase member engagement.
Below are three unique ways HELIOS can help support Medicare Advantage payers looking to improve star quality ratings.
1. Predictive Analytics for More Proactive, Effective Care
Having a 360-degree view of the member is integral in delivering real-time optimal care experiences that help keep members healthy. Understanding what services a member already has in place, what services they still need, and if they receive them is essential.
And being able to identify and address potential health concerns earlier is key as well. Today, supporting the health of members requires a proactive approach. And this relies on predictive analytics that provides a more detailed and comprehensive patient view.
HELIOS uses predictive analytics and powerful algorithms to process large quantities of diverse data sets within seconds to generate insights that tee up care management teams to provide the right care services and interventions, to the right patient, at the right time. This also helps predict and identify patients who are at risk for poor health outcomes by flagging those with high-risk factors.
Third, HELIOS can help sift through historical and real-time data to identify health-threatening patterns of behavior, such as routinely missing appointments or non-adherence to medications and plans of care.
- Care managers can proactively reach out to understand why a member is not getting the care, services, or items they need. This could be because the member is forgetful or may be due to an associated SDOH – such as no access to transportation to pick up medications or attend appointments. The care manager can intervene by coordinating transportation to medical appointments and delivery of medications, and helping the member with developing a calendar to track appointments.
- Gives care managers a clearer picture of how to provide better care and more effectively engage members. For example, AI analytics may help reveal that a member’s blood sugar continues to be high despite taking medications as prescribed. The care manager can explore contributing factors, such as diet, inactivity, etc., and collaborate with the provider to determine if referrals to a specialist or diabetes classes are appropriate.
And with HELIOS, this smart and comprehensive patient view is available to healthcare professionals that need it. Providers, along with their clinical and support staff, can access a more complete picture than the one within the limitations of their clinical systems. They can also directly engage with the care team on authorization requests, claim status, care planning, referrals, interventions, and medication management. Providers and care managers and coordinators work in tandem to deliver better care and support the member’s needs across the continuum from medications to screenings and treatment adherence, thus supporting better member health and experiences on-going.
2. More Effective, Collaborative Management of Chronic Conditions
For members suffering from chronic illnesses and complex conditions, effective disease management can help provide better outcomes and reduce the costs of care.
HELIOS has a configurable set of disease management workflows and capabilities uniquely designed to help improve the health of those with chronic conditions while reducing unnecessary utilization and avoidable complications, like emergency department visits. And for payers with populations who may have a high prevalence of chronic conditions, being able to efficiently improve chronic complex condition management and care is key.
Below are nine additional ways that HELIOS can help payers support populations with chronic complex conditions.
- Proactively find individuals who can benefit from disease management with advanced identification and stratification algorithms
- Use smart assessments with branching logic and scoring that capture detailed and specialized information about the presence and treatment of key diagnoses and comorbidities to track the progress of a disease and treatment
- Auto-populated care plans based on smart assessment results unique to members’ individual health and condition needs
- Automated referral creation, episode generation, and assignment and tasking to streamline disease management by the care team for more efficient care management
- Care teams can set personalized goals, barriers, and interventions for members to enable personalized guidance, support, and monitoring to best drive sustainable health and behavioral changes
- Schedule home visits, engage in secure video conferences, and order a range of services to support individuals with chronic conditions
- Multidisciplinary care team – care managers, clinicians, pharmacists, behavioral health specialists, and social workers- can all work within HELIOS via role-based access and contribute to educating, guiding, and treating high-complexity patients for a coordinated care approach
- Integrated virtual tools help care teams maintain check-ins with patients who may need extra support and reassurance or help to keep them on track for managing their condition(s)
- Educational resources and materials to help members and their caregivers understand health conditions, how to manage them, and the importance of medication and care plan adherence
3. Multi-channel Communication with Members
Today’s members look to a suite of communication methods for their health. And when it comes to member experiences and accessing care, virtual tools are a key addition to more traditional methods such as email and direct mail.
Within HELIOS, integrated virtual health tools can help a payer support members’ health by offering additional communication channels and furthering member engagement and education initiatives.
enables secure outbound text message communication from the care team to individual members directly from HELIOS. Members may prefer texting to traditional phone calls, and by using text messages, care managers can increase proactive communication efforts and better engage members. And can work as a digital member engagement tool to provide a secure, easy way to embrace virtual visits, making care more equitable and available to anyone with access to a smartphone, tablet, or computer.
Together, integrated virtual health tools within HELIOS can provide the following benefits to support member health and experiences.
- Identify and close care gaps earlier and faster so that members don’t go without the care they need
- Proactive care outreach to improve adherence to provider instructions, care plans, or medication regimens
- Provide members with more personalized choices and instant access to care without requiring transportation or time off including access to health education resources and more
- Address social determinants of health (SDOH) to improve population health equity and individual member health outcomes
- Increase member engagement and self-activation by making it quick and easy to engage with care teams instantly, since there’s no complicated software to download, eliminating typical tech challenges
- Improve outcomes since care teams can easily identify care gaps, create personalized care plans, and make faster, more informed decisions
- Empower members to engage via communication methods they prefer
- Securely exchange files with members including key educational resources a member may need
- Connect with members via videoconference to provide member support, bridge gaps between providers and members, walk through educational resources or care plans, etc.
- Help members get the care they need faster, ultimately driving better health outcomes
Looking for more ways to improve Medicare Advantage care management? Read: 11 Ways HELIOS Can Help Payers with Complex Medicare Populations.