Jason Z. Rose, MHSA

, a leading healthcare technology company focused on medication adherence. With nearly 25 years of experience in healthcare technology, Jason is a serial healthcare IT entrepreneur, focused on launching disruptive products that drive digital health innovation and value-based care outcomes.

Unplanned hospital readmissions are a perennial concern in health care. In addition to being disruptive and stressful for health plan members, avoidable readmissions cost the health care system an estimated $17 billion dollars annually.

Reducing all-cause hospital readmissions rates is crucial for Medicare Advantage (MA) plans that want to perform highly on the influential Star Ratings scale. Readmission rates are an important key performance indicator and may influence member decisions about choosing a plan partner.

Research shows that Medicare Advantage members have 

 of risk-adjusted 30-day readmissions than their traditional Medicare counterparts. And since 

 of 30-day readmissions are directly tied to medication adherence reconciliation issues, MA plans have a clear opportunity to improve quality by delivering more comprehensive, timely medication reconciliation services to recently discharged members.

Gaps in Medication Reconciliation Lead to Avoidable Readmissions

Understanding why a patient returns to the hospital soon after discharge is key to preventing avoidable readmissions and solving the challenges of follow-up care. Medication reconciliation is at the heart of the solution. In Measurement Year 2021, more than half of the Star Rating quality measures are weighted to medication-related measures, including the Part C measure for Medication Reconciliation Post Discharge (MRP).

, MRP “shows the percent of plan members whose medication records were updated within 30 days after leaving the hospital. To update the record, a doctor or other health care professional looks at the new medications prescribed in the hospital and compares them with the other medications the patient takes.”

As CMS actively reevaluates the role and expands the scope of medication reconciliation in its MA quality measures, plans will need to implement new strategies for addressing the root causes of avoidable readmissions for their members. In addition to considering a new COVID-19 vaccine Star measure, CMS announced the Contract Year 

 change from the MRP measure to the Transition of Care measure. CMS defines a transition of care as the movement of a patient from one setting of care to another. Settings of care may include hospitals, ambulatory primary care practices, ambulatory specialty care practices, long-term care facilities, home health, and rehabilitation facilities. This is a material change that will impact how a significant number of plans manage transitional care.

In a sample cohort analysis for a Dual Special Needs (DSNP) MA plan in 2020, AdhereHealth conducted individualized postdischarge medication reviews via telepharmacy for 5000 MA members in 2020. In that sample, an alarming 61.9% had at least 1 drug therapy problem (DTP) that would have gone unaddressed without telepharmacy outreach (Figure 1).

Additional findings from the cohort include (Figure 2):

These pervasive issues lead to medical errors and complications that drive health plan members directly back to the emergency room and inpatient setting.

How can health plans identify and address medication reconciliation problems to keep members on track with recovery after a recent hospitalization? To improve their MRP measure and reduce cost of care, health plans should consider adopting an approach that leverages real-time data and timely telepharmacy outreach as part of a strategic, proactive plan.

Integrating Digital Data With Personalized, Pharmacist-Led Outreach

The difficulties begin with the inability to capture accurate medication histories from patients as they are admitted into the hospital and continue along various touch points within the health care system. Challenges are especially acute among patients who have complex medication regimens to treat chronic conditions and those who are managing multiple social determinants of health (SDOHs).

For example, paper-based processes for collecting and adjusting medication records can be slow, costly, and prone to errors. While health plans may have access to medication history data, they do not always have the latest information about admissions and discharges—or any medication changes that occurred during these events—leaving them unable to quickly connect with members.

With the right technologies and predictive analytics capabilities, health plans can access clinical histories, claims data and pharmacy data in real time. Artificial intelligence can automatically capture and analyze all relevant data, and then immediately prompt specially trained pharmacists to conduct an outbound call to complete MRP measures within 48 hours of discharge. Documentation of the MRP with a medication action plan is sent electronically to the provider and successful HEDIS gap closure for the measure is submitted with the filing for a zero-dollar medical claim.

What’s more, these modern systems have the ability to collect accurate, comprehensive data about SDOH, which have historically been difficult to gather, standardize, and share through existing health information technology systems.

Pharmacists can and should take a more active role in leveraging these data assets to improve MRP processes. Studies have found that 

pharmacy-led interventions may help reduce readmissions 

to the hospital, particularly among high-risk patients. These services do not require face-to-face encounters, which is why a growing number of health plans are now using a tele-pharmacy approach to conduct MRP measures, identify potential adverse drug reactions, and highlight cost-saving substitute opportunities.

Because adherence to medication is critical in the days after a postdischarge window, the speed at which plans can connect data with the member and a pharmacy professional to review medication information is vital.

Reaching out to the patient within the first 5 days of discharge can achieve significant results. A telepharmacy approach enables MRP measures to be conducted quickly while opening the conversation to several other SDOH factors that may prevent patients from following through on medication instructions, such as language barriers or access to transportation and other fundamental challenges. Ensuring the patient has been provided with health literacy content on their conditions, which medications to discontinue, and new medications that need to be filled is key. Ensuring the patient has continuity of care with their community physician will help reinforce the components of the MRP, especially if the doctor has timely access to the document.

A Combined, Ongoing Effort to Improve Outcomes for Members

Keeping patients out of the hospital means staying on top of the health status of everyone in a health plan all year long. For MA plans, this often requires a shift in mindset and the adoption of new models for delivering holistic care. Access to comprehensive patient data from all points of the care continuum, in real time, can enable this to happen. Leveraging that data with the power of predictive analytics will enable pharmacists to strategically engage with members and conduct MRPs while simultaneously addressing SDOH issues and working to improve other key Star Rating measures.

Take the real story of Mr Wilson, a patient in an MA plan (not his actual name to protect his privacy). Mr Wilson was prescribed valsartan, budesonide/formoterol, ranolazine, and 5 other medications for his hypertension, angina, arrhythmias, and chronic obstructive pulmonary disease. After being hospitalized for a recent stroke that left him unable to read or write, he became nonadherent to his medication. Before the nonadherence could result in an unplanned readmission, a skillful, licensed pharmacist from AdhereHealth reached out to Mr Wilson and educated him on the importance of adherence, especially when managing multiple chronic conditions. Mr Wilson reported forgetfulness and admitted that he’d lost one of his prescriptions. His outreach specialist coordinated a conference call with his pharmacy to replace the lost medication, and he was referred to health plan care management to address home health assistance. 

Especially in the age of COVID-19, which significantly complicates the admission and discharge landscape, health plans will need to adopt new, more personalized and effective ways to address medication-related issues to prevent unnecessary recurring hospitalizations.

Although the issue of avoidable readmissions cannot be solved via medication reconciliation alone, it is perhaps the most critical piece of the puzzle. As such, having pharmacists play a leading role in the process due to their expertise makes logical sense. Equipping these experts with holistic, predictive analytics will only heighten their effectiveness on behalf of members both immediately after a discharge and throughout the entirety of their healthcare experience. Taking the opportunity to ensure the patient has a good understanding of their new medication regimen, access to pharmacy and community physician follow-up is key. Providing the primary care physician and the patient with timely access to the completed MRP assessment can make a difference in avoiding a readmission.

Articles

Medicare Advantage plans have a clear opportunity to improve quality by delivering more comprehensive, timely medication reconciliation services to recently discharged members.

Contributor: Postdischarge Medication Reconciliation Is the Key to Reducing Hospital Readmissions

The coronavirus disease 2019 (COVID-19) vaccination supply chain has so far rightfully focused on health care workers and the elderly, but there is not a strategy to reach underserved and marginalized populations representing the highest risk for mortality. COVID-19 exposed the lack of health equity that has existed for decades. While the world has grappled with responding to the pandemic, the evidence shows that the most vulnerable Americans are those with significant social determinants of health (SDOH) issues. These populations most disproportionately affected by SDOH include ethnic minorities with low socioeconomic status. These 5 key determinants include economic stability, education, social and community context, health and health care, neighborhood, and built environment. SDOH issues constitute 70% of health care outcomes, revealing that it’s not the genetic code, it’s the zip code.

Beyond the health equity issues and morality, the pandemic’s economic cost includes enormous financial burden in hospital care costs ranging from $51,000 to $78,000 per admission, based on age. With hundreds of thousands of deaths in 2020, the CDC estimates 4.1 million hospitalizations, which would represent more than $200 billion dollars.

There is an urgent need to accelerate vaccination distribution for vulnerable Americans by overcoming SDOH problems. Americans residing in certain urban and rural regions are often ill-equipped to navigate the health care system complexities or have no local access to care. COVID-19 has magnified this issue with respectively higher hospitalization rates and now lack of accessible vaccination. How can tens of millions of our most vulnerable be reached and supported to ensure health equity is achieved to improve the direst outcomes in the nation? An innovative combination of available technology, timely data, local social services, and outbound telehealth could rapidly overcome these issues. Further, an emphasis on addressing SDOH is critical, which includes health literacy regarding the importance of the vaccination. For example, in North Carolina, Black Americans represent 22% of the state’s population and 26% of the health care workforce but only 11% of the vaccine recipients so far. White Americans, a category that North Carolina classifies as Hispanic and non-Hispanic Whites, represent 68% of the population and 82% of those who are vaccinated. The CDC data show that Black, Hispanic, and Native American Americans are dying from COVID-19 at nearly 3 times the rate of White Americans.

How can the government and private organizations accelerate vaccinations for high-risk, vulnerable individuals? By converging together, public-private partnerships can rapidly increase vaccination distribution by prioritizing the underserved, engaging these marginalized populations through intelligent telehealth, and resolving SDOH issues.





Governments and private health plans have timely, accessible health care claims and demographic data that can be used to create analytics to prioritize higher risk, underserved individuals. Are the individual’s chronic conditions placing them at higher risk for COVID-19 hospitalization? What is the individual’s medication adherence rates for these conditions? Where does the individual live?



Utilization of telehealth is up by an incredible year-over-year increase of 3000%, yet the capabilities are largely inbound health calls lacking analytics or training to overcome SDOH issues. Telehealth clinicians can be trained in COVID-19 vaccination prescreening, health literacy education, and social services. With all the odds stacked against them, high-risk Americans need support to get vaccinated. Many of these vulnerable Americans have other life priorities that require additional support to overcome barriers to care that deprioritize vaccinations until addressed. What many people take for granted are unsurmountable problems that will get in the way of scheduling and traveling to a vaccination appointment.



Telehealth clinicians need training and access to transportation services that meet the individual’s needs (eg, rideshare, paratransport, companion) to ensure vaccination can safely occur. Other SDOH issues such as medication adherence, access to a physician, or food insecurities are more urgent issues than a preventive vaccination. A well-trained clinician with intelligent clinical workflow technology and access to social services can address SDOH issues in real time.

It is morally ethical and fiscally responsible to vaccinate the most vulnerable. The solution needs to be a combination of public-private partnership to pivot our nation from a dark period in history. With the supply of vaccinations more readily available over the next few months, all adult Americans can be vaccinated in the first half of 2021. However, by focusing on the SDOH as a central issue for COVID-19 vaccination, the highest-risk and marginalized populations would overcome deep-rooted mistrust in the health care system to overcome barriers of care. Vaccinating the most vulnerable populations could be our nation’s catalyst to finally prioritizing health equity issues and improving value-based outcomes.

Jason Z. Rose, MHSA, is CEO of AdhereHealth.

There is an urgent need to accelerate vaccination distribution for vulnerable Americans by overcoming problems involving social determinants of health.  

Contributor: It’s the Zip Code, Not the Genetic Code—The Need for an Equitable Vaccination Strategy

 found that more than half of older Americans put off medical treatment during the first month of the pandemic. Social distancing is helping curb the spread of coronavirus disease 2019 (COVID-19). However, avoidance of typical medical treatment places quality of care for seniors at higher risk, amplifying challenges for the most vulnerable parts of the population. Across the country, older adults with chronic and disabling health conditions or intellectual disabilities have been delaying essential medical care out of fear of the coronavirus. The consequence is an alarming trend—one that may be equally harmful to seniors’ health—medication nonadherence. At the end of the 2020 contract year, AdhereHealth conducted a large national telepharmacy outreach to Medicare Advantage (MA) members that qualified for Star Ratings Care of Older Adults (COA) measures. Of the membership assessed, 55% had at least 1 drug therapy problem (DTP) that would have gone unaddressed without the pharmacist outreach.

According to the CDC, the Special Needs Plan (SNP) population is disproportionately at risk of severe illness from exposure to COVID-19. 

that older people with preexisting conditions are more susceptible to needing hospitalization, intensive care, or a ventilator compared with younger patients. Last year, dual-eligibles (those eligible for both Medicare and Medicaid) that contracted the virus were hospitalized at a rate 

 than beneficiaries with Medicare only. A growing body of evidence confirms that social determinants of health (SDOH) and medication adherence issues are key drivers of these health outcomes. Indeed, a concerning number of older adults already have unresolved DTPs because of disruptions in their medical care during the pandemic.



Now, with COVID-19 cases in the United States on the rise again, so are corresponding fears about contracting the virus during a doctor’s visit. Many seniors, especially dual-eligibles, remain hesitant to return to health services. Beyond the traditional provider setting, health plans have typically used doctors or nurse practitioners to provide targeted home assessments for higher risk consumers. However, COVID-19 concerns have led beneficiaries to decline these visits at a much higher rate in 2020 as well. Moreover, researchers now warn viral mutations may cause yet another COVID-19 wave, potentially limiting the efficacy of vaccines and prolonging the march toward immunity even further. All of this means seniors will likely remain isolated and continue to defer care for the foreseeable future. And without support for SDOH challenges, emerging problems with medication adherence could get even worse unless MA SNPs change their approach to providing needed care.

CMS requires all 3 types of SNPs (C-SNP, D-SNP, and I-SNP) to perform the COA quality measures in the 2021 contract year. To avoid degradation of Star Ratings, SNPs must mitigate the impact of delay in care and reassess their strategy for delivering essential care to at-risk seniors. Intelligent clinical workflow tools can support these efforts by integrating data to provide a holistic view of the patient, including SDOH issues that may contribute to nonadherence. Modern solutions allow providers to document things like food access challenges, copayment issues, transportation access, and other barriers that may prevent access to care or medication. 

The criteria for COA requires all SNPs to document an annual Medication Review and Pain Assessment for each consumer 66 years and older. These two measures factor into the MA plan’s overall Star Ratings score. Updated COA measures will also include a Functional Status Assessment, which was retired but is coming back in contract year 2023 with a revised question set. CMS has announced Functional Status Assessment will be a display measure in contract year 2022.


Disruptions in health care caused by the pandemic have made it more of a challenge for SNPs to perform necessary COAs. As a result, AdhereHealth found a troubling number of seniors were at risk of adverse drug reactions, allergic reactions, and other safety issues related to their medications.

Beyond quality of care concerns, the importance of COA quality measures cannot be underestimated. For one, consumers who did not receive COA assessments are more likely to submit a negative response in Consumer Assessment of Healthcare Providers & Systems (CAHPS) consumer experience surveys. CMS recently made material changes for the weighting measures related to CAHPS. The Agency for Healthcare Research and Quality (AHRQ) orchestrates CAHPS surveys and supplemental items designed to capture patient experience with health care services at multiple levels of the delivery system. CMS recently determined that CAHPS measures will be quadruple-weighted beginning in contract year 2021, equaling 32% of the overall MA Star Ratings score. Plans that fall below CMS’s 4-star threshold will lose out on reimbursements from the nearly $7 billion Quality Bonus Payment pool—to the tune of approximately $500 per member per year. 

 ask beneficiaries (or caregivers) about their experience with their health plans and its provider network. Consumers are specifically asked:


Has your health plan helped you get needed care?

How well do you understand your medication information?

How many times did you have an in-person, phone, or video visit with your personal doctor about your health?

Delayed doctor visits because of concerns surrounding COVID-19 create a conundrum for SNP when it comes to CAHPS, especially given their timing. These surveys are collected in the spring between March and May. Experts 

 for most Americans until as late as next fall.

But the value of COA assessments extends even further. Combined, the 3 COA measures represent the components necessary to create an advanced care plan, which every SNP must have as part of the Model of Care (MOC) Review and Cure Processes. The MOC provides the foundation to ensure that the unique needs of each enrollee are identified and addressed by the SNP, promoting quality, care management, and care coordination processes. The NCQA scores each of the clinical and nonclinical elements of the MOC as part of its approval process. SNPs 

 in order to receive final approval status for up to 3 years. In other words, SNPs must ensure COA services take place for a majority of members in order to continue operating as an MA plan.

Scaling an Intelligent Clinical Workflow Platform

To avoid a concerning ripple effect, forward-thinking SNPs are using pharmacy-led telehealth to conduct consumer outreach.The combination of predictive analytics and detailed clinical workflow software has proven essential to preserving access to needed care for beneficiaries of SNPs who have been reluctant or unable to go to the doctor amid quarantines.

These plans utilize data (eg, medical claims, pharmacy claims, hospital discharge, Healthcare Effectiveness Data and Information Set, and consumer surveys) to identify at-risk consumers. Licensed pharmacists conduct proactive outreach to vulnerable consumers via telehealth phone calls. Artificial intelligence within the clinical workflow platform will send automatic reminders prompting follow-ups to help patients stay on track with their health, from their very base needs to remembering to take daily medications.

As Winston Churchill said, “never let a good crisis go to waste.” Due to the pandemic, the telehealth industry became a prominent feature of the health care system that will surely be a permanent fixture for efficiency and consumer convenience. The demand for care through these virtual settings should persist due to several factors. However, many of these elderly and at-risk consumers do not have access to a smart phone or computer. Therefore traditional virtual visits are not a viable solution.

In this scenario, pharmacy-led telehealth outreach plays a critical role enabling SNPs to deliver necessary COA assessments. What’s more, the pharmacists are also uniquely qualified to identify DTPs and other gaps in case. For example, if a consumer is on diabetes medicine the pharmacist can help them facilitate getting a glycated hemoglobin check, clinician-documented blood pressure, or eye exam. In addition, pharmacists are specially trained to work with at-risk consumers to uncover and address SDOH issues by connecting consumers with community resources, such as meal services and transportation.

Even in the best of circumstances (ie, without a global pandemic), SNPs often hit hurdles when trying to follow through on COA quality measures. 

 that older adults receive only about half their recommended care, with varying quality and limited attention to social issues impacting their health (ie, SDOH). COVID-19 is making matters even worse. The following powerful real-world examples come from a sampling of over 50,000 COA assessments conducted by AdhereHealth last fall amid the second surge of the pandemic.

A patient for whom English is a second language told pharmacists she had not seen a doctor due to COVID-19 and transportation issues even though she was experiencing excruciating pain in her arm that was radiating into her spine. She did not have a caregiver and had become depressed. Her landlord used to check in on her, but now the landlord himself had health problems and could no longer come. This made her fearful about her housing situation. 

Another patient told pharmacists she was being cared for by her niece, who was COVID-19 positive. Other patients revealed problems with insurance coverage, injuries from falls, and missed physical therapy appointments.

Perhaps most concerning were the significant number of instances in which patients and their clinicians identified issues with medications, many of which were moderate to severe. Specifically, the analysis found more than 55% of patients receiving a COA had at least 1 DTP that would otherwise have gone unaddressed if not for the specially trained pharmacist who connected with these consumers via phone.

Here are the DTP statistics associated with this cohort of patients:


These findings are cause for alarm, not only because medication issues put these already vulnerable consumers at a higher risk for an adverse medical events, but also because medication adherence is critical to improving overall health outcomes—and in turn, 

integral to an organization’s MA Star Rating.

(52%) of the weighting for the aggregate rating is anchored to medication-related quality measures. Taken together, COA, CAHPS, and medication-related quality measures will drive 61.1% of Star Ratings for the 2021 contract year (and even more in years to come). Given the magnitude of these quality measure weightings combined with the pandemic-exacerbated barriers endemic to these vulnerable populations, SNPs must reassess their strategies now to ensure success.

2020 may have come to a close, but it will be some time until we truly return to “normal.” In January, the pandemic entered its 10th month in the United States. Nationally, coronavirus-related delays now account for thousands of delayed appointments and canceled doctor’s visits. Consumers still aren’t comfortable with their health plan’s in-home assessment options. Critical gaps in care will remain a challenge to address in the Medicare Special Needs sphere. SNPs need to adapt to this world and rethink their approach to ensuring quality access to care.

Despite the myriad of challenges posed by the pandemic, the crisis has also created opportunities to care for this population in new and more effective ways. Pharmacy-led telehealth can provide a marked advantage for conducting COA assessments. Additionally, these impacts go beyond COA to also affect medication-adherence measures as well as CAHPS consumer experience and SDOH-related issues. The key is reaching the right consumers at the right time, using an intelligent clinical workflow software platform to engage consumers over time in a holistic way that leverages every touchpoint with consumers, and making SDOH issues a priority in every conversation. These strategies will position SNPs for Star Ratings success during the pandemic and for years to come.

Pharmacy-led telehealth strategies will position Special Needs Plans (SNPs) for Star Ratings success during the pandemic and for years to come.

Contributor: Implementing Pharmacy-Led Telehealth Strategies to Help Medicare Advantage SNPs Improve Care for Older Adults Amid COVID-19 and Beyond

Contract Year 2021 Star Ratings formula updates

, the agency sent a clear message—Medicare Advantage Prescription Drug (MAPD) plans need to get serious about consumer experience and continue high focus on medication adherence. MAPD plans that fall below the 4-Star threshold risk losing approximately $500 per member per year reimbursement improvement as a part of the nearly $7 billion annual 

 allocated by CMS. What’s more, the changing weights put Dual-eligible Special Needs Plans (DSNP) (ie, Medicare/Medicaid enrollees) at the highest risk. As the QBP pool is finite, it is Darwinism for health care where only the plans with the strongest quality plans can compete. These higher quality plans are required to use the increased value-based reimbursement toward more member benefits and thereby have a better product to compete for consumers.

Consumer Assessment of Healthcare Providers and Systems (CAHPS

 survey measures (Figure 1) were already double weighted (2x) in Contract Year 2020. However, in the 2021 contract year, CMS 

 of these measures by quadruple-weighting (4x) them to be 32% of the overall Star Rating.

CAHPS surveys ask beneficiaries (or caregivers) about their consumer experience with, and ratings of, their providers (eg, hospitals, home health care, hospitals) and health plans. Per CMS, the intention of these statistically validated surveys is to illustrate “perceived key aspects of their care, not how satisfied they were with their care…such as how they experienced critical aspects of health care, including communication with their doctors, understanding their medication instructions, and the coordination of their healthcare needs.” All surveys officially designated as CAHPS surveys have been 

, which is overseen by the Agency for Healthcare Research and Quality (AHRQ).

On the surface, MAPD plans have maintained stable performance on CAHPS scores overall by averaging 3.34 Stars and 3.33 Stars in Contract Year 2019 and 2018. However, MAPD plans face higher exposure to not reach the overall 4-Star threshold for the QBP under the updated weighting methodology. As proactive plans place higher focus on CAHPS leading up to the March 2021 surveys, consumer experience measures will drive further differentiation between high performers and low performers next year.

Not all plans will weather these measurement weighting adjustments equally. For example, deeper analysis into the measures by plan type reveals DSNPs perform quite differently as compared to other MAPD plans (Figure 2). CMS already adjusts quality and adherence measures for DSNPs, but does not provide a curve for CAHPS. DSNPs performed 5.8% worse for CAHPS measures as compared to non-DSNP plans in Contract Year 2018 when the weighting was 1.5x. The weighting shifting to 4x in 2021 will have a tremendous impact to DSNPs. Further, while all plans must generally place greater higher focus on CAHPS, DSNP plans performed better in Contract Year 2019 (see Figure 2) on Part D than non-DSNP plans likely due to improved prescription drug plan benefits (eg, cost sharing more favorable to members). Conversely, DSNPs performed far worse than non-DNSPs on Part C CAHPS measures.

Consumer experience, therefore, has become a business imperative. MAPD plans and in particular DSNP plans, must address CAHPS measures as part of their daily consumer engagement to maximize quality measures improvement. CAHPS surveys are 

 between March and May each year, so plans that are focused on the 2021 contract year in late 2020 leading up to the reporting period will be at an advantage.

It is clear, however, that consumer experience must be a year-round focus as a part of other quality improvement activities, most notably those focused on medication-related measures. An analysis of Medicare Advantage Part C and D measures for the 2021 contract year reveals 52% of experience improvement, process, and outcomes measures are anchored to medication use (Figure 3). Further, there are two 5x measures that are also impacted by CAHPS measures: C29 – Health Plan Quality Improvement and D06 - Drug Plan Quality Improvement. 

Indeed, to drive material improvement of consumer experience measures plans will need to take a holistic and consumer-centric approach to providing access to care. Even concerted efforts to improve individual processes are unlikely to move the needle sufficiently or maximize results. Consumer experience can reflect the totality of a plan’s operation—as the customer experiences it. The approach to consumer experience measures must focus broadly across the organization to encompass any area that touches the consumer.

Barriers to Consumer Experience Improvement

There may be a wide array of barriers to consumer experience improvement, but 2 fundamental challenges for health plans include:

 Operationally, Consumer Experience transcends departments such as Pharmacy, Health Services, Quality, Member Services, and Marketing. While a single medication adherence measure, such as D10 - Medication Adherence for Diabetes Medications, might be the focus of the pharmacy team, the overall consumer experience may not be any team’s primary focus.

Moreover, a diabetic consumer likely has several other gaps to be addressed during the contract year across Part C and Part D measures, such as Eye Exam, Kidney Disease Monitoring, Blood Sugar Controlled, Care of Older Adults, Statins Use for People with Diabetes, and Medication Therapy Management. However, most health plans do not consider the number of outreaches from different departments, physician offices and vendors attempting to reach out to the same member throughout the year to close each gap. Therefore, the consumer experience will be poor (and inefficient) if these outreach efforts are not calibrated throughout the year.



 At the root of CAHPS consumer experience scores are consumers’ ability to access needed care. Barriers to care for many consumers include issues like lack of transportation, health literacy, lack of funds for health care services or pharmacy copayments, and the inability to navigate administrative hurdles.

Gaps in SDOH have been exacerbated in the wake of COVID-19, particularly in vulnerable dual eligible populations. Given the fundamental nature of these issues in determining the health of populations, plans must consider investing proactive outreach to high-risk consumers to assess their needs and provide additional support. In particular, drilling down into individual situations is vital to understanding and removing any SDOH, or socioeconomic issues, impeding a consumer’s ability to fill a prescription and take medication. For example, a consumer who needs help getting to a medical appointment may also need transportation to a pharmacy following the appointment; otherwise, the consumer may go straight home, unable to fill the prescription.

Eliminating co-payments for chronic medications can alleviate barriers to care. Switching consumers to combination medications that treat two conditions at once is another approach to breaking down barriers. For example, consumers with diabetes can be put on a combined insulin-statin medication, which the plan purposely puts on a lower formulary tier, instead of having to take separate medications. The consumer is now ingesting one less drug and incurs lower out-of-pocket costs. This approach helps engage the consumer so they are more open to working with the health plan on adhering to their medications.

Best Practices for Improving Health Plan Consumer Experience

A rigorous, effective approach to improving consumer experience will need to vary by plan, but plans that want to best position themselves for future Star Ratings success would be wise to consider these strategies:

. Consumers simply do not care whose department is responsible for their experience, they just want a good experience and action. Similarly, consumers have grown accustomed to customer relationship management (CRM) tools that enable seamless communications across touchpoints. In health care, such continuity across encounters will become increasingly important as consumer expectations matter more to health plan performance. To approach consumer experience from the consumer’s perspective, plan leaders will need their organizations to work across departments and to center operational improvements around the consumer. For example, if a consumer with a gap in care calls with a benefit question, health plans have the opportunity to simultaneously address any barriers causing the care gap. Regardless of who in the organization has consumer contact, they must have a full picture of the consumer’s needs and capitalize on every opportunity to better understand that consumer and improve their access to care.

This approach, paired with integrated data and intelligent clinical workflow platforms, can extend from plans to their provider networks. Through seamless workflows and data-sharing, MAPD plans can engage their provider partners as fellow champions of medication adherence and consumer experience improvements.


Orient the plan around what it can do rather than on what it cannot

. Most health plans are not set up to optimize consumer experience, nor is the health system overall. Lack of follow-up care might reflect burdens created by the plan’s referral requirements. It is also increasingly important for plans to help coordinate care, access medication, and reduce nonmedical barriers to care. Tackling these types of barriers may be necessary to unlocking greater improvements in key measures like “getting needed care.” Documenting these discrete actions in the CRM so that there are specific actions taken and ongoing reporting will help show consumers how plans are driving better care.


Embrace customer data and seek hidden truths

. Health plans are experts at conducting customer satisfaction surveys, but CAHPS samples are relatively small and can be easy to dismiss if the results are unfavorable. Instead of explaining why results might not be all positive, plans will benefit from sober examination of the data. What kernels of truth emerge that plans can exploit for improvement?

Any health plan leader can look at their survey scores and see measures that have room for improvement. Deeper analytics, though, can reveal real drivers of performance, and point to potential strategies for improvements based on root-cause analysis.



The Benefits of Consumer Experience Improvements

Improving consumer experience and medication adherence measures will have the direct, near-term effect of improving Star Ratings. Not only will improved Star Ratings increase reimbursement to payers, the funds will create richer benefits to attract and retain membership.

The challenge is how to improve consumer experience while remaining efficient. Plans need a holistic technology platform to support this effort. The system should provide systematic predictive analytics to identify highest-impact focus areas, and intelligent clinical workflows for improving key Star Rating measures simultaneously. Analytics are also vital for revealing points of leverage—those areas on which plans can focus to drive the greatest overall results, and developing tangible action plans with effective interventions that enable plans to compete for value-based care reimbursements in the highly competitive Medicare Advantage vertical.

Leveraging technology to strategically engage with consumers and respond to their needs will position the plans for the future as CMS continues to increase their expectations for consumer experience. Longer term, CMS has signaled they are considering including Net Promoter Scores (NPS) in future Star Ratings. A standard measure of customer loyalty, NPS captures how likely a customer is to recommend the organization to others. To do well on this measure, plans will need more loyal enthusiasts (“promoters”) than unsatisfied customers (“detractors”). Good consumer experience will increasingly be more competitive.

Summary of Necessary Operational Structure Changes and Technology Investments

Amazingly, despite the incredible focus on the multibillion dollar Star Ratings QBP pool, health plans almost exclusively use antiquated case management tools, spreadsheets and transactional measure campaigns to close gaps. Even the most advanced health plans that focus on consumer experience and tackling SDOH use free text case management notes to document the consumer interaction. This approach eliminates the ability to use the interaction to drive the next step in the consumer’s adherence journey. Further, free text cannot be reported or assessed in any meaningful way.

In addition, it is very common for health plans to have a disconnected approach to consumer engagement strategies and tactics. Moreover, Pharmacy teams are accountable for Part D measures, Quality teams are accountable for HEDIS measures and Member Services and/or Marketing are accountable for CAHPS/HOS consumer experience measures. The result is a disconnected approach to consumer and provider engagement, higher health plan resource costs, and lower consumer experience.

With consumer experience increased to be 32% of the weighting, and medication-related measures representing 52% of Star measures, health plans would be wise to consider implementing a platform that enables a comprehensive approach to improving their Star Ratings.

Using predictive analytics to target at-risk consumers proactively year-round with a data-driven clinical workflow through a CRM system is critical to compete. Modern tools leverage near real-time health plan data (eg, medical claims, pharmacy claims, hospital discharge, HEDIS, consumer surveys) to produce near real-time target and stratification of at-risk measures to guide clinicians in their engagement with consumers and their doctors. The CRM tool should be robust in features, enabling real-time clinical focus to address SDOH, leverage health plan benefits, available community resources and pharmacy enrollment to maximize the engagement. Tackling SDOH actions in a discrete method, not free text notes, will enable additional analytics and reporting.

The effect of a broader focus on the consumer’s experience, and of this outreach to improve their care, can be directly correlated to Part C and Part D CAHPS measures. These investments would support the plan’s internal operational cadence enabled by an integrated consumer approach to drive better value-based care.

Reflection and commitment to improvement will not only be essential to survive the near-term Star Ratings methodology changes, it will position plans to succeed long term as CMS continues to raise the bar in the future.

Dual-eligible Special Needs Plans are at highest risk with newest CMS changes.

Jason Z. Rose, MHSA

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