Earning Top Medicare Advantage Ratings Requires Data, Ambitious Goals

September 18, 2018 - Succeeding in the highly competitive Medicare Advantage (MA) market requires more than just a sense that there are financial gains to be had in this growing health insurance segment.

Payers that wish to reap some of the many financial rewards of becoming an MA plan sponsor also need to deliver impeccable services to consumers, both in the clinic and at the help desk.

The Medicare Advantage Star Rating system is the most visible mark of success with the challenges of improving experiences, delivering quality care, and improving long-term outcomes for vulnerable beneficiaries.

Health plans that do not achieve the coveted five-star rating for their services risk falling behind the pack in an increasingly crowded field of offerings.

Julie Wright, Chief Medical Officer for Dean Plan Health, knows that hitting the five-star goal isn’t easy.  It’s even harder to do in the first year of operating a new Medicare Advantage offering.

READ MORE: Reference Pricing Models for Prescription Drugs May Contain Costs

But setting the tone for success from the very beginning was key to doing just that, she told HealthPayerIntelligence.com.  

“We really wanted to go in shooting for five stars — adhering the right compliance and regulatory arrangements and making sure we knew exactly how to be successful within each Medicare Advantage area,” Wright said. “That also included building a growth strategy in order to scale our MA capabilities. A five-star entry was very intentional.”

Dean Health Plan also provides original Medicare products and services, but saw Medicare Advantage as an opportunity to improve quality and choice for its Medicare members.

“The most important decision-making factor for entering Medicare Advantage is to determine how this product aligns with an organization’s goal to provide superior services and high-quality outcomes for its membership,” Wright said. “Payers should ask themselves how they can help to expand those offerings and opportunities for beneficiaries.”

When Dean Health Plan launched its first MA option in 2017, the organization started by asking itself those very questions and preparing carefully for both short-term and long-term success.  

READ MORE: Handful of States Propose Lower ACA Premium Rates for 2019

Health plans need as much information about their internal readiness as they do about the market they will be entering, Wright said.

Before launching a new product, an MA plan should gather as much performance data and financial data as possible from each department, she said. The information allows a health plan to determine where a plan can succeed and what aspects of its operations may require attention.

“The MA entry was a health plan-wide initiation of a brand-new product line. And that's not something to undertake lightly,” Wright said. “We wanted to make sure that we could develop that, do it well, scale it, and grow it in a way that would align with our members’ needs. And we also wanted to evaluate if we could perform well for our members and employer groups.”

Collecting this data allowed Dean Health Plan to make an informed decision about whether the time was right to enter the Medicare Advantage market, and how to position its offerings to meet each of the MA Star Ratings criteria.

“We went through and evaluated our service capabilities compared to what each star measurement category asks for,” Wright said. “It took careful evaluation to determine where the best opportunities are to achieve high star ratings and be successful.”

READ MORE: How Payers Can Improve the Value of Long-Term Support Services

“We then performed some analysis about which stakeholder would ‘own’ those different areas,” she continued. “We evaluated if a certain performance measure would require management from within the health plan or if a provider would be responsible. Then we started to link the responsible stakeholders to each measure.”

The payer also paid close attention to the compliance and regulatory requirements that form a core part of developing a new plan offering.

“This is absolutely one of the critical things a new Medicare Advantage plan has to prepare for,” Wright emphasized.  “The preparation for the rigor, discipline, planning, and oversight for all of the compliance and regulatory aspects is critical. I cannot underestimate how important that is.”  

“Our health plan had real strengths after planning around compliance and making sure that the plan reported on the right measures, she continued. “We ensured that we were compliant in every single step that we had to be, to honor our obligations both to CMS and to our members.”

Steering committees constantly monitor the quality and performance of each program, she added.

The plan leverages an extensive physician network of 2400 providers, 28 hospitals and 187 primary care sites to provide services such as embedded pharmacy programs, chronic disease management services for MA, and beneficiary engagement programs. The steering committees ensure that the programs within the network are geared towards achieving a five-star rating

“Steering teams, provider collaboration, constant oversight, and continuous monitoring of our MA programs drove our overall results,” Wright said.

Dean Health Plan boasts five-star ratings for diabetes care, care coordination, healthcare quality rating, beneficiary healthcare access, and medication adherence. Wright attributes the success to effective collaboration and the benefits of health IT.

Dean Health Plan’s quality department is largely responsible for making sure that beneficiaries not only had high-quality care, but also have quick access to healthcare services. The quality department assesses opportunities for clinical care providers to improve quality.  Health IT systems help to organize and report on care management data.

 “It’s very important that we have a close working relationship between our quality department here at the health plan and our contracted providers,” Wright said. “The quality department also ensured that care coordination teams knew exactly what services a patient needed as the beneficiary received care.”

The payer’s integrated pharmacy programs also help drive high star ratings, Wright said.

Dean Health Plan created a medication management program and an embedded pharmacy program at the point of care.

“Any Medicare Advantage patient member getting care would have the opportunity to have a dedicated pharmacist working to see what they needed,” Wright explained. “People who are at higher risk, such as those taking multiple medications, are enrolled into our pharmacy programs so we can help them maintain adherence.  Our adherence programs evaluate if and when patients are on the right medications for their condition.”

Dean Health Plan currently offers five Medicare Advantage health maintenance organization (HMO) plans and six supplemental benefits for MA beneficiaries. Wright is hopeful that Dean Health Plan will expand its MA business segments beyond its current offerings with new health plan types and additional benefits that focus on quality.

“Some of those new plans and benefits may focus on better or broader health-related services, such as wellness initiatives to keep a member healthy or active,” Wright said. “We think we've developed a little bit more in that area and of course we want to explore new opportunities for expansion.”

“A payer can start out in the area where it thinks it can achieve high-quality in Medicare Advantage, and then increase its efforts and skills sets,” Wright concluded. “And of course, that's part of our initial strategy that we're continuing to see through.”