Optimizing quality with proactive outreach

Star Ratings have a significant impact on both the competitive and economic success of Medicare Advantage plans. Plans that receive at least four stars receive financial bonus payments, which can provide a 5 to 10 percent increase in funding. This means a four-star plan with 1 million members could potentially bring in ~$500 million in bonuses alone.¹ And because rebates are used to subsidize premiums, reduce copayments and deductibles or finance enhanced benefits (such as vision and dental), plans that get higher rebates have an advantage in attracting new enrollees.

The drive to innovate and improve the quality of health services is significant. The US Centers for Medicare & Medicaid Services (CMS) evaluates a variety of quality measures to assess the quality of plans and ultimately assigns each an overall Star Rating. Five quality categories are measured, each with a specific weight as it relates to its contribution toward the overall Star Ratings score.

With annual Star Ratings due to come out in October, now is the time to be thinking about plan improvements. Because member populations can differ significantly by location and makeup, there is certainly no one-size-fits-all solution. However, higher member engagement leads to better outcomes, thus the key to driving performance improvements is in reaching and motivating members. We have found that proactive outreach is a proven way to increase consumer experience, service and overall health outcomes, working to raise Star Ratings and overall plan success.

Defining proactive outreach

A proactive approach to member outreach goes well beyond just phone calls or letters in response to an observed gap in care. It comprises proactive, real-time digital and pharmacist-led interventions that drive improved health engagement and adherence. Many members in these populations already have an ongoing, trusted relationship with their pharmacists. Health care professionals are among the most trusted professions, and 84% of Americans trust their pharmacist.³

We leverage predictive analytics to help identify the right interventions, using the right communication methods for each individual member based on behavioral insights. The communication channels could include text messages, pushed notifications through our mobile applications, or even in-person pharmacy visits. Regardless of how the intervention occurs, this personalized approach ensures we are optimizing all the data available to us to drive the best possible health outcome.

The role of the pharmacist in closing gaps in care

Pharmacists have a unique, trusted role in the health care ecosystem. Thanks to an innovative care tool known as the Pharmacist Panel, CVS Health pharmacists use individualized clinical insights derived from our analytics engine to help provide appropriate counsel to patients, either in store or by phone. For example, the Pharmacist Panel may prompt the pharmacist to:

• Suggest ways to optimize medications to boost adherence
• Recommend vaccines, screenings, labs and lifestyle changes
• Connect the member to other resources within their health plan, such as care management and prescription home delivery

Pharmacists can help get to root causes of gaps in care, and help the member close those gaps – looping in the provider if appropriate.

Part of the success of these proactive outreach results is because plans are able to customize the focus areas, whether it be a breast cancer screening or diabetes medication adherence. Because each population is different, plans can customize their approach and member needs.

Implementing new strategies to increase Star Ratings takes time and effort, but the benefits can be significant. The financial benefits of even small improvements add up, from reimbursement rates to bonuses and additional enrollment time through the year. And having a higher rating means that when compared to other options on the Medicare Plan Finder website, consumers will see your plan more favorably too.