Hi, everyone. This is Lucas Voss with Becker's
Healthcare. Thanks so much for tuning in to
the Becker's Payer Issues podcast series.
Today, we're going to be talking about boosting
star ratings, the key to health plan
success.
And joining me for today's discussion, I'm very
excited to have her, Whitney Eubanks, VP product
management at PointClickCare.
Whitney, thanks so much for being here today.
It's great to have you. Thanks for having
me. Yeah. Excited to be here and just
to discuss this topic.
Absolutely. Could you just introduce yourself to your
audience to our audience really quickly?
Sure. Yeah. So like you mentioned, vice president
of product management for PointClickCare's
acute and payer business where we're really focused
on building out the country's largest real time
care coordination network.
I've been at PointClickCare for a few years
now. I've spent nearly twenty years in product
marketing and product management roles, primarily in health
care technology.
Then Then a lot of my time working
with health plans and pharmacy benefit managers
through the course of my career. So this
is a space and a topic near and
dear to my heart.
And it's great to have you. And we
are talking about
boosting star ratings. But before we're doing that,
we have to talk about
why we have to boost them
and the recent drop in star ratings for
major health plans.
What's at stake
if don't they don't improve,
and why are we seeing those drops?
Yeah. Yeah. It's a good question. I mean,
the drops are pretty dramatic. So just last
year, eighty percent of Medicare Advantage enrollees were
in four star or better plans,
but now that number is down to sixty
four percent.
Wow.
And and five star plan enrollment fell off
a cliff. It went from twenty two percent
down to two percent. So, yeah, the question
is what what's going on here?
And really, it's two main things. First, CMS
changed
how they calculated the cut points. Essentially,
they removed the lowest performing plans from the
equation,
which Mhmm. Raise the bar really across the
board, and I think caught a lot of
plans a bit off guard.
But the second thing is that the competition
is just getting tougher. So if you're not
improving year over year, you're actually falling behind.
But in terms of of impact and what's
at stake, there's real money on the line
here. So if you are a plan and
you drop below four stars, you're losing
quality bonus payments, which can impact the bottom
line and really hurt the ability to attract
new members as well.
I was gonna say, I mean, at the
end of the day,
name of the game is bottom line for
most folks, I would assume. What's the impact
on
a health plan's
bottom line? And then in turn, what are
some of those ripple effects that you're seeing
that impact patient care and also long term
sustainability?
Yeah. I mean, in in short, it's a
big deal. So a drop from four and
a half to three and a half stars
can slash a plan's operating income by up
to 40%.
Mhmm. And when revenue drops, the plans start
cutting back on extra benefits that make them
competitive in the first place. So you've kinda
got this vicious cycle going on. Lower ratings
means fewer members,
which means less revenue to invest in quality
care, and eventually that starts to impact
patient outcomes, patient experience, and the plans are
are kind of stuck playing catch up.
And then you're having to deal with what
you've mentioned earlier too. There's more and more
competition. Right? So if you're not improving,
you're going to be even further caught into
that cycle, and it keeps going and going
and going.
So what steps can health plans take right
now to turn declining scores around and and
stay ahead in an increasingly competitive landscape?
I think most importantly, it's understanding where CMS
is going.
So they're shifting weight from patient experience to
clinical outcomes, and real time is the name
of the game. Your best chance to optimize
outcomes is actually during some kind of health
inflection point. So especially those transitions right after
an emergency department or an inpatient encounter.
That's when patients are the most vulnerable, but
they're also the most receptive to behavior change
or
taking action on next steps that are required,
after those encounters.
So that means that measures like TRC, transitions
of care, the follow-up after ED visit for
high risk patients or what they call FMC,
and plan all cause readmissions, PCR, which is
actually triple weighted now. Those measures are front
and center in star ratings just to to
give a couple examples.
And if you focus on transitions
and and really improving that experience and reducing
readmissions around those critical points, you may also
boost your patient satisfaction as well, which, of
course, can have an indirect impact on CAHPS
surveys.
And then in turn, like you said, that's
what's going to get those stars up. In
terms of how we're doing this,
how can real time data access and exchange
enhanced care coordination between health plans, hospitals, and
providers
lead to more of a boost in those
star ratings and and getting them up?
Yeah. It's a game changer. I mean, if
you're still using claims data to manage care,
you're you're already way too late. Real time
clinical data helps care teams act fast right
when the patient needs that care the most.
Actually, my mother-in-law works as a care manager
at a health plan, and she's even, had
responsibility
for training these care teams. And she's shared
with me so many stories
about some of the challenges that that those
roles face. But what really stuck out to
me is,
her saying, you know, I have precious few
moments with a member. And if I am
spending that time
asking for information about what happened when you
were in the hospital, what were your discharge
instructions, then I'm not spending
ultimately will improve star ratings, if you're not
using that precious time talking about how we
can help guide their next steps of care.
And it's very difficult to get the outcomes
that we all want those outcomes that ultimately
will improve star ratings if you're not using
that precious time
very wisely.
So, you know, from my perspective, this is
a very solvable problem with real time encounter
alerts, real time clinical data. Care teams can
jump in immediately after a hospitalization.
They can work to close care gaps. They
can coordinate with providers or automate
intelligence heading over to providers who need to
do follow-up care and ultimately reduce readmissions.
But at the end of the day, it
really just comes down to being proactive
instead of reactive, which is exactly what CMS
is rewarding now. Yeah. And
like you've just talked about, it comes back
to full circle what we talked about earlier.
Right? It all has ripple effects on patient
care. On that long term sustainability that we
talked about. It's a very important piece. Whitney,
thanks so much for taking the time today
and and walking us through this. This is
an important topic, and and I'm glad you
you spent some time with us today.
Yes. Thank you so much for having me.
Absolutely. And we also want to thank our
podcast sponsor, PointClickCare.
You can tune into more podcasts from Becker's
Healthcare by visiting our podcast page at beckerspayer.com.