1
00:00:00,080 --> 00:00:01,839
Hi, everyone. This is Lucas Voss with Becker's

2
00:00:01,839 --> 00:00:03,439
Healthcare. Thanks so much for tuning in to

3
00:00:03,439 --> 00:00:05,700
the Becker's Payer Issues podcast series.

4
00:00:06,240 --> 00:00:08,580
Today, we're going to be talking about boosting

5
00:00:08,880 --> 00:00:11,460
star ratings, the key to health plan

6
00:00:11,839 --> 00:00:12,339
success.

7
00:00:12,835 --> 00:00:15,634
And joining me for today's discussion, I'm very

8
00:00:15,634 --> 00:00:18,355
excited to have her, Whitney Eubanks, VP product

9
00:00:18,355 --> 00:00:19,574
management at PointClickCare.

10
00:00:20,435 --> 00:00:22,195
Whitney, thanks so much for being here today.

11
00:00:22,195 --> 00:00:24,355
It's great to have you. Thanks for having

12
00:00:24,355 --> 00:00:26,260
me. Yeah. Excited to be here and just

13
00:00:26,260 --> 00:00:27,640
to discuss this topic.

14
00:00:28,019 --> 00:00:30,739
Absolutely. Could you just introduce yourself to your

15
00:00:30,739 --> 00:00:32,759
audience to our audience really quickly?

16
00:00:33,299 --> 00:00:35,939
Sure. Yeah. So like you mentioned, vice president

17
00:00:35,939 --> 00:00:37,719
of product management for PointClickCare's

18
00:00:38,179 --> 00:00:40,875
acute and payer business where we're really focused

19
00:00:40,875 --> 00:00:43,674
on building out the country's largest real time

20
00:00:43,674 --> 00:00:45,135
care coordination network.

21
00:00:45,594 --> 00:00:47,515
I've been at PointClickCare for a few years

22
00:00:47,515 --> 00:00:50,635
now. I've spent nearly twenty years in product

23
00:00:50,635 --> 00:00:53,274
marketing and product management roles, primarily in health

24
00:00:53,274 --> 00:00:53,935
care technology.

25
00:00:54,475 --> 00:00:55,780
Then Then a lot of my time working

26
00:00:55,780 --> 00:00:58,359
with health plans and pharmacy benefit managers

27
00:00:58,820 --> 00:01:00,659
through the course of my career. So this

28
00:01:00,659 --> 00:01:02,820
is a space and a topic near and

29
00:01:02,820 --> 00:01:03,799
dear to my heart.

30
00:01:04,340 --> 00:01:05,859
And it's great to have you. And we

31
00:01:05,859 --> 00:01:06,674
are talking about

32
00:01:07,314 --> 00:01:10,515
boosting star ratings. But before we're doing that,

33
00:01:10,515 --> 00:01:11,895
we have to talk about

34
00:01:12,915 --> 00:01:14,694
why we have to boost them

35
00:01:15,395 --> 00:01:18,515
and the recent drop in star ratings for

36
00:01:18,515 --> 00:01:19,895
major health plans.

37
00:01:20,939 --> 00:01:22,159
What's at stake

38
00:01:22,700 --> 00:01:24,560
if don't they don't improve,

39
00:01:24,939 --> 00:01:26,640
and why are we seeing those drops?

40
00:01:27,340 --> 00:01:28,859
Yeah. Yeah. It's a good question. I mean,

41
00:01:28,859 --> 00:01:31,500
the drops are pretty dramatic. So just last

42
00:01:31,500 --> 00:01:34,875
year, eighty percent of Medicare Advantage enrollees were

43
00:01:34,875 --> 00:01:36,894
in four star or better plans,

44
00:01:37,275 --> 00:01:39,114
but now that number is down to sixty

45
00:01:39,114 --> 00:01:40,015
four percent.

46
00:01:40,555 --> 00:01:41,055
Wow.

47
00:01:41,435 --> 00:01:43,674
And and five star plan enrollment fell off

48
00:01:43,674 --> 00:01:45,719
a cliff. It went from twenty two percent

49
00:01:45,719 --> 00:01:47,719
down to two percent. So, yeah, the question

50
00:01:47,719 --> 00:01:49,500
is what what's going on here?

51
00:01:50,200 --> 00:01:53,420
And really, it's two main things. First, CMS

52
00:01:53,799 --> 00:01:54,299
changed

53
00:01:54,679 --> 00:01:57,195
how they calculated the cut points. Essentially,

54
00:01:57,734 --> 00:02:00,855
they removed the lowest performing plans from the

55
00:02:00,855 --> 00:02:01,355
equation,

56
00:02:01,895 --> 00:02:04,454
which Mhmm. Raise the bar really across the

57
00:02:04,454 --> 00:02:06,215
board, and I think caught a lot of

58
00:02:06,215 --> 00:02:08,075
plans a bit off guard.

59
00:02:08,694 --> 00:02:10,530
But the second thing is that the competition

60
00:02:10,750 --> 00:02:12,830
is just getting tougher. So if you're not

61
00:02:12,830 --> 00:02:15,250
improving year over year, you're actually falling behind.

62
00:02:16,269 --> 00:02:18,110
But in terms of of impact and what's

63
00:02:18,110 --> 00:02:20,030
at stake, there's real money on the line

64
00:02:20,030 --> 00:02:21,709
here. So if you are a plan and

65
00:02:21,709 --> 00:02:24,064
you drop below four stars, you're losing

66
00:02:24,364 --> 00:02:26,924
quality bonus payments, which can impact the bottom

67
00:02:26,924 --> 00:02:29,965
line and really hurt the ability to attract

68
00:02:29,965 --> 00:02:31,344
new members as well.

69
00:02:31,805 --> 00:02:33,084
I was gonna say, I mean, at the

70
00:02:33,084 --> 00:02:33,985
end of the day,

71
00:02:34,620 --> 00:02:36,620
name of the game is bottom line for

72
00:02:36,620 --> 00:02:39,360
most folks, I would assume. What's the impact

73
00:02:39,419 --> 00:02:39,919
on

74
00:02:40,379 --> 00:02:41,360
a health plan's

75
00:02:41,659 --> 00:02:44,300
bottom line? And then in turn, what are

76
00:02:44,300 --> 00:02:46,560
some of those ripple effects that you're seeing

77
00:02:46,925 --> 00:02:49,965
that impact patient care and also long term

78
00:02:49,965 --> 00:02:50,465
sustainability?

79
00:02:51,405 --> 00:02:53,245
Yeah. I mean, in in short, it's a

80
00:02:53,245 --> 00:02:55,564
big deal. So a drop from four and

81
00:02:55,564 --> 00:02:57,324
a half to three and a half stars

82
00:02:57,324 --> 00:02:59,884
can slash a plan's operating income by up

83
00:02:59,884 --> 00:03:00,944
to 40%.

84
00:03:01,324 --> 00:03:03,550
Mhmm. And when revenue drops, the plans start

85
00:03:03,550 --> 00:03:05,709
cutting back on extra benefits that make them

86
00:03:05,709 --> 00:03:08,110
competitive in the first place. So you've kinda

87
00:03:08,110 --> 00:03:11,090
got this vicious cycle going on. Lower ratings

88
00:03:11,150 --> 00:03:12,370
means fewer members,

89
00:03:12,669 --> 00:03:15,629
which means less revenue to invest in quality

90
00:03:15,629 --> 00:03:17,889
care, and eventually that starts to impact

91
00:03:18,405 --> 00:03:21,284
patient outcomes, patient experience, and the plans are

92
00:03:21,284 --> 00:03:23,145
are kind of stuck playing catch up.

93
00:03:23,925 --> 00:03:25,365
And then you're having to deal with what

94
00:03:25,365 --> 00:03:27,525
you've mentioned earlier too. There's more and more

95
00:03:27,525 --> 00:03:30,104
competition. Right? So if you're not improving,

96
00:03:30,485 --> 00:03:32,564
you're going to be even further caught into

97
00:03:32,564 --> 00:03:35,090
that cycle, and it keeps going and going

98
00:03:35,090 --> 00:03:35,830
and going.

99
00:03:36,210 --> 00:03:38,210
So what steps can health plans take right

100
00:03:38,210 --> 00:03:40,770
now to turn declining scores around and and

101
00:03:40,770 --> 00:03:43,430
stay ahead in an increasingly competitive landscape?

102
00:03:44,210 --> 00:03:47,909
I think most importantly, it's understanding where CMS

103
00:03:47,969 --> 00:03:48,629
is going.

104
00:03:49,264 --> 00:03:52,224
So they're shifting weight from patient experience to

105
00:03:52,224 --> 00:03:55,665
clinical outcomes, and real time is the name

106
00:03:55,665 --> 00:03:58,384
of the game. Your best chance to optimize

107
00:03:58,384 --> 00:04:00,865
outcomes is actually during some kind of health

108
00:04:00,865 --> 00:04:04,930
inflection point. So especially those transitions right after

109
00:04:04,930 --> 00:04:07,750
an emergency department or an inpatient encounter.

110
00:04:08,209 --> 00:04:11,169
That's when patients are the most vulnerable, but

111
00:04:11,169 --> 00:04:14,150
they're also the most receptive to behavior change

112
00:04:14,209 --> 00:04:14,709
or

113
00:04:15,090 --> 00:04:17,235
taking action on next steps that are required,

114
00:04:17,794 --> 00:04:19,014
after those encounters.

115
00:04:19,394 --> 00:04:22,514
So that means that measures like TRC, transitions

116
00:04:22,514 --> 00:04:25,474
of care, the follow-up after ED visit for

117
00:04:25,474 --> 00:04:27,574
high risk patients or what they call FMC,

118
00:04:28,194 --> 00:04:31,220
and plan all cause readmissions, PCR, which is

119
00:04:31,220 --> 00:04:34,259
actually triple weighted now. Those measures are front

120
00:04:34,259 --> 00:04:36,500
and center in star ratings just to to

121
00:04:36,500 --> 00:04:37,639
give a couple examples.

122
00:04:38,259 --> 00:04:39,879
And if you focus on transitions

123
00:04:40,339 --> 00:04:44,145
and and really improving that experience and reducing

124
00:04:44,145 --> 00:04:47,584
readmissions around those critical points, you may also

125
00:04:47,584 --> 00:04:50,145
boost your patient satisfaction as well, which, of

126
00:04:50,145 --> 00:04:52,464
course, can have an indirect impact on CAHPS

127
00:04:52,464 --> 00:04:52,964
surveys.

128
00:04:54,240 --> 00:04:55,839
And then in turn, like you said, that's

129
00:04:55,839 --> 00:04:58,399
what's going to get those stars up. In

130
00:04:58,399 --> 00:05:00,579
terms of how we're doing this,

131
00:05:01,199 --> 00:05:03,860
how can real time data access and exchange

132
00:05:04,079 --> 00:05:06,959
enhanced care coordination between health plans, hospitals, and

133
00:05:06,959 --> 00:05:07,459
providers

134
00:05:08,145 --> 00:05:10,305
lead to more of a boost in those

135
00:05:10,305 --> 00:05:12,324
star ratings and and getting them up?

136
00:05:13,024 --> 00:05:14,705
Yeah. It's a game changer. I mean, if

137
00:05:14,705 --> 00:05:17,105
you're still using claims data to manage care,

138
00:05:17,105 --> 00:05:19,985
you're you're already way too late. Real time

139
00:05:19,985 --> 00:05:22,699
clinical data helps care teams act fast right

140
00:05:22,699 --> 00:05:25,040
when the patient needs that care the most.

141
00:05:25,740 --> 00:05:28,459
Actually, my mother-in-law works as a care manager

142
00:05:28,459 --> 00:05:30,539
at a health plan, and she's even, had

143
00:05:30,539 --> 00:05:31,039
responsibility

144
00:05:31,339 --> 00:05:33,579
for training these care teams. And she's shared

145
00:05:33,579 --> 00:05:34,959
with me so many stories

146
00:05:35,464 --> 00:05:37,384
about some of the challenges that that those

147
00:05:37,384 --> 00:05:39,865
roles face. But what really stuck out to

148
00:05:39,865 --> 00:05:40,685
me is,

149
00:05:41,305 --> 00:05:43,944
her saying, you know, I have precious few

150
00:05:43,944 --> 00:05:46,105
moments with a member. And if I am

151
00:05:46,105 --> 00:05:47,324
spending that time

152
00:05:47,865 --> 00:05:49,819
asking for information about what happened when you

153
00:05:49,819 --> 00:05:49,910
were in the hospital, what were your discharge

154
00:05:49,910 --> 00:05:50,525
instructions, then I'm not spending

155
00:05:51,240 --> 00:05:53,864
ultimately will improve star ratings, if you're not

156
00:05:53,864 --> 00:05:56,489
using that precious time talking about how we

157
00:05:56,489 --> 00:05:59,113
can help guide their next steps of care.

158
00:05:59,113 --> 00:06:01,738
And it's very difficult to get the outcomes

159
00:06:01,738 --> 00:06:04,754
that we all want those outcomes that ultimately

160
00:06:04,754 --> 00:06:07,235
will improve star ratings if you're not using

161
00:06:07,235 --> 00:06:08,455
that precious time

162
00:06:08,915 --> 00:06:09,654
very wisely.

163
00:06:10,194 --> 00:06:12,035
So, you know, from my perspective, this is

164
00:06:12,035 --> 00:06:14,915
a very solvable problem with real time encounter

165
00:06:14,915 --> 00:06:17,955
alerts, real time clinical data. Care teams can

166
00:06:17,955 --> 00:06:20,589
jump in immediately after a hospitalization.

167
00:06:21,129 --> 00:06:23,370
They can work to close care gaps. They

168
00:06:23,370 --> 00:06:25,629
can coordinate with providers or automate

169
00:06:26,009 --> 00:06:28,330
intelligence heading over to providers who need to

170
00:06:28,330 --> 00:06:31,310
do follow-up care and ultimately reduce readmissions.

171
00:06:32,330 --> 00:06:33,290
But at the end of the day, it

172
00:06:33,290 --> 00:06:34,935
really just comes down to being proactive

173
00:06:36,134 --> 00:06:38,694
instead of reactive, which is exactly what CMS

174
00:06:38,694 --> 00:06:41,194
is rewarding now. Yeah. And

175
00:06:41,894 --> 00:06:42,694
like you've just talked about, it comes back

176
00:06:42,694 --> 00:06:44,634
to full circle what we talked about earlier.

177
00:06:44,694 --> 00:06:47,574
Right? It all has ripple effects on patient

178
00:06:47,574 --> 00:06:50,120
care. On that long term sustainability that we

179
00:06:50,120 --> 00:06:52,600
talked about. It's a very important piece. Whitney,

180
00:06:52,600 --> 00:06:54,040
thanks so much for taking the time today

181
00:06:54,040 --> 00:06:55,479
and and walking us through this. This is

182
00:06:55,479 --> 00:06:57,319
an important topic, and and I'm glad you

183
00:06:57,319 --> 00:06:58,860
you spent some time with us today.

184
00:06:59,240 --> 00:07:01,180
Yes. Thank you so much for having me.

185
00:07:01,479 --> 00:07:03,375
Absolutely. And we also want to thank our

186
00:07:03,454 --> 00:07:04,355
podcast sponsor, PointClickCare.

187
00:07:05,214 --> 00:07:07,375
You can tune into more podcasts from Becker's

188
00:07:07,375 --> 00:07:11,394
Healthcare by visiting our podcast page at beckerspayer.com.