In today’s increasingly competitive Medicare Advantage environment, managing your Star ratings is becoming even more critical to plans so they can retain membership and achieve their financial goals. For many plans, integrated care management has become a key tool for delivering the level of care quality that helps members stay healthy and provides a positive healthcare experience. 

Understanding Medicare Advantage Star Ratings

Star ratings are used by the Centers for Medicare and Medicaid Services (CMS) to help Medicare Advantage members make knowledgeable decisions when selecting a plan. Plans are given an overall rating based on a number of quality and performance factors, many centered not only around how the plan supports member health, but also the overall member experience—including how well the plan handles member problems, complaints, and appeals.

Star ratings simplify the complex metrics CMS uses into a simple 1- to 5-star rating system that shows how current members rate the plan, how the plan performed based on industry standards, and how plans compare to each other, all so Medicare Advantage members can make better, more informed choices.

As an advantage, any plan rated four stars or above receives quality bonuses from CMS, which can enable them to add benefits, services, and resources to support member health and well-being. The higher the rating, the higher the bonus. Plans with lower ratings, on the other hand, are leaving more money on the table.

Integrated Care Management Drives Better Care

Medicare Advantage members are often complex, with comorbidities that complicate treatment and behavioral and social determinants that serve as barriers to care. A holistic approach that addresses member behavioral and psychosocial issues alongside medical care can go a long way toward improving your quality of care. Plans that use an integrated care management approach can improve their care quality and efficiency—which in turn can improve member satisfaction. And better care and satisfaction drive higher Star ratings.

To give your complex members the comprehensive care they need, your integrated care management programs should have a number of capabilities:

• Collaboration across interdisciplinary teams to eliminate siloes and ensure that medical, behavioral health, and community services are communicating and informed.
• Support for social determinants of health (SDOH) to connect members with the community resources that can help them with the psychosocial issues (e.g., housing instability, food insecurity, and transportation barriers) that prevent quality care.
• Optimized chronic disease management that coordinates and tailors multidisciplinary care to individual needs according to best-practice protocols.
• Preventative care with proactive measures such as preventative screenings, vaccinations, and wellness programs.
• Member engagement throughout their care journey to foster strong relationships and encourage active participation in care decisions.
• Data-driven quality insights and reporting that help you track, monitor, and evaluate outcomes and program effectiveness, identify areas for improvement, measure performance against quality benchmarks, and ensure compliance.

Strategies to Improve Star Ratings

Integrated care management has great potential to drive meaningful improvements in patient outcomes and overall plan performance, ultimately boosting your Star ratings. To be successful, you’ll need to foster collaboration and partnerships across providers, community-based organizations, and social service agencies to address the diverse needs of your membership. Make sure to prioritize health equity and cultural competence in care delivery to ensure equitable access to high-quality care for all beneficiaries to improve outcomes and satisfaction.

But care management alone isn’t enough.

Appropriate access to the right care at the right time is key to optimizing care delivery and Star performance. That means that your utilization management processes need to align with care management in a way that ensures timely access to services to minimize disruptions to care. Inefficiencies such as authorization delays and difficult-to-navigate appeals and grievances processes result in a lack of responsiveness that adds friction—and creates a negative member experience that will hurt your ratings.

Prior authorization is a particular pain point for members. Long authorization approval times can delay critical care, impacting the outcomes of vulnerable patients. Making the process less painful through automation that speeds processing and eliminates errors, and through decision support that enables staff to make clinically sound decisions using objective criteria, will make the process better for everyone.

Invest in a robust care management technology platform that supports seamless coordination and communication across interdisciplinary teams so you can deliver timely whole-person care to your members and track the results. Make sure you care management solution integrates seamlessly with utilization management to ensure timely authorization processing and best-practice decisions. And, continuously monitor and evaluate the quality and financial performance of your programs, adjusting your strategies as needed to achieve your goals for outcomes and Star ratings improvement. 

InfoMC’s Incedo Platform Delivers Integrated Care Management

InfoMC’s Incedo Enterprise Care Management offers a holistic approach to care delivery that helps you lower costs and improve outcomes for complex and vulnerable populations. With decades of experience integrating behavioral health and social determinants with medical care, we offer integrated care and utilization management that can help you support your Medicare Advantage, dual-eligible, and special needs plan (SNP) programs more effectively. Plus, we can help you proactively monitor and manage performance to improve quality and member experience to drive Star ratings.

Ready to learn more? Schedule a consultation and demo today.

Additional Information:

From Frustration to Satisfaction: How to Transform the Prior Authorization Experience