In a recent conversation with Susan Morse, Executive Editor at Healthcare Finance News, for HIMSS TV’s Digital Checkup, I had the opportunity to discuss the growing challenges facing Medicare Advantage (MA) insurers and the importance of adapting new strategies to meet the moment.
A Recalibration of CMS Star Ratings
Over the past two years, and continuing into the next, CMS has implemented significant changes to the Star Ratings program. These include:
- Adjusted cut points
- Revised weighting of certain measures
- A new approach to the reward factor.
For many MA plans, these updates will require extensive recalibration of previous strategies that worked. While in the past, plans focused on familiar metrics and predictable workflows for Stars, today’s environment requires refreshed approaches to maintaining or improving quality ratings and associated revenue streams.
High Utilization Trends
Care utilization rates began rising notably in 2022. Initially, many assumed this was a temporary rebound effect following the disruption of COVID-19. However, we now recognize this trend reflects something more systemic. Members are pursuing more care.
In addition to increased utilization, many plans have also expanded benefits to both entice and retain new members as well as stand out from their competitors. Additions like over-the-counter cards and gym memberships, which add value but also increase utilization.
Health plans should consider how they will improve integration with care services, including inpatient care, ER visits, and preventive services. Enhanced care coordination and access to more timely and correct data will become even more essential for plan teams to manage these new layers of care effectively.
The Cost Impact of SDOH
Multiple studies and extensive anecdotal evidence point to a clear link between unaddressed social needs and increased healthcare utilization. For example, individuals experiencing housing instability are significantly more likely to rely on emergency departments or experience inpatient readmissions.
To achieve better health outcomes and control costs, insurers must take a proactive role in closing these gaps. This is particularly relevant for both MA and D-SNP members, many of whom face ongoing income and access challenges that may not have been fully addressed during earlier stages of their healthcare.
Member-Centered Care and Support
At 86Borders, we specialize in strengthening the connection between health plans and their members. Our team supports individuals through every stage of the care journey – helping them address SDOH needs, schedule appointments, coordinate transportation, and establish a relationship with primary care and specialty providers.
By closing these social gaps, we enable plans to not only reduce unnecessary utilization costs and navigate changing regulations, but also improve the overall member experience and outcomes.
The Time to Adapt is Now
Medicare Advantage plans are facing a pivotal moment. To succeed in this new environment, health plans must go beyond traditional strategies and embrace a more holistic, member-centered approach – one that accounts for both medical needs and the social factors that influence them.
At 86Borders, we’re proud to be part of that solution.
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