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  • Writer's pictureBrandon Hedgspeth

Navigating the Shifting Landscape of Medicare Advantage Ratings

Introduction:


In a notable development, the landscape of Medicare Advantage (MA) programs has witnessed a 45% decrease in the number of plans earning a coveted 5-star rating. This significant shift can be attributed, in part, to the implementation of Tukey, a popular statistical tool, outlier deletion methodology, which strategically removes outliers before applying mean comparisons.


Quality Over Patient Satisfaction:


A noteworthy trend is the increasing prominence of Healthcare Effectiveness Data and Information Set (HEDIS) measures in determining star ratings. This shift underscores a growing emphasis on the quality of care provided, surpassing traditional considerations such as patient satisfaction, operational efficiency, and pharmacy services. This is made clear by the increase of weight on quality scores over others.


Financial Implications:


The financial stakes in the MA arena are high, with the difference between a 3-star and a 4-star plan translating to millions of dollars on average. Despite approximately 74% of MA enrollees contracting with plans rated 4 stars or higher, only 42% of plans with prescription coverage achieve this commendable rating.


Statistics and Financial Impact:


The MA landscape encompasses approximately 31 million beneficiaries, with three times more contracts witnessing a decline in ratings compared to those that experienced improvement. Alarmingly, 74 plans faced the consequence of losing nearly $1.5 million in Quality Bonus Payments.


Medication Adherence Challenges:


The struggle for high scores in medication adherence metrics is evident. Diabetes and hypertension medication adherence both average a score of 2.6 out of 5, while statin use in people with diabetes lags with an average score of 2.4. These figures underscore the challenges plans face in ensuring optimal adherence to prescribed medications.


Evolution of Measures:


Several key measures are set to transform the evaluation process. The All-Cause Readmissions measure will now carry three times the weight, transitioning from 1x to 3x. Similarly, Breast Cancer Screening will shift from an administrative measure to an electronic clinical data systems measure. Furthermore, Transitions of Care and Follow-up after Emergency Department visits for patients with multiple chronic conditions will be introduced as an additional measure.


Conclusion:


As the Medicare Advantage landscape undergoes dynamic changes, stakeholders must adapt to the evolving criteria influencing star ratings. The intersection of financial implications, quality metrics, and evolving measures demands a strategic approach from MA plans to not only maintain but enhance their ratings in this ever-shifting healthcare environment.


Grapefruit Health has innovative solutions to help you stay on top of your Star Rating to ensure your organization is getting optimal quality, performance, and reimbursement. Not only do our outreach solutions help you in these aspects, but we can also help to retain and keep current employees satisfied. Our clinical student workforce is also a novel talent pipeline to your clinicians of the future.


As it relates to the new rules, we can help in the following ways:

  1. Engage with your members who are non-compliant with medications and convert them to compliant via 3rd-year pharmacy students by calling them regularly

  2. Engage all your lower acuity ED discharge members within 48 hours of discharge and ensure they have what they need not to be readmitted via nursing students

  3. Engage with patients to educate them on digital health literacy.

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