Earlier this year, we highlighted three areas of innovation for health plans after the Center for Medicare and Medicaid Services (CMS) Proposed Rule was announced. Now that many of the proposals have been finalized and more are on the way, health plans need to make significant changes to their approach, or they could see a substantial reduction in their Medicare Advantage Star Ratings in the years to come.
“The best time to start was yesterday. The next best time is now.” -Unknown.
We are breaking down some of the most significant changes for CY 2024 and beyond, what it means for health plans, and what can be done now to prepare.
The biggest change causing a stir in the industry is CMS replacing the Reward Factor with the Health Equity Index (HEI) for 2027 Star Ratings. This means CMS will specifically reward health plans for delivering high quality care to vulnerable populations. Implementing the Health Equity Index will incentivize plans to prioritize reducing health disparities and encourage a uniform standard to achieve the highest level of health for all their members.
If plans are not already centering their most vulnerable members, this change could significantly impact Star Ratings due to the change in how and when this measure will be calculated. Data from measure years 2024 and 2025 will be used to calculate the first Health Equity Index that impacts 2027 Star Ratings. Therefore, plans that do not begin to take action on a robust health equity action plan (before 2024) will take a hit to their Star Ratings.
The Health Equity Index is also likely to remain a moving target, allowing for adjusted performance thresholds and the inclusion of additional Social Determinants of Health considerations as needs evolve. Plans will need to continue to anticipate changes and be able to accommodate a wide range of SDOH.
Evaluate your health disparities data. Are you receiving the data you need to accurately address the social risk factors your members face? If your data has glaring gaps, vulnerable members could still be overlooked due to low engagement or lack of quality responses to social needs screenings.
Boost engagement with your vulnerable populations. To encourage members to engage, it’s important to look at the reasons they are not engaging in the first place. While these can differ from person to person (lack of trust, time, transportation, etc.), behavioral science principles will better equip health plans to overcome biases or barriers that exist. These biases can prevent member engagement, but operationalizing concepts such as loss aversion, endowment effect, personalization, and positive reinforcement help boost engagement even in the hardest-to-reach populations.
Don’t hesitate in implementing a multi-faceted approach to addressing SDOH. Creating an actionable health equity plan requires a keen understanding of the social and financial barriers vulnerable member populations are facing and how to manage them adequately. By incorporating culturally competent support, SDOH centered rewards, and personalized engagement backed by behavioral science, health plans can target the root of these barriers. Connecting with a proven digital health partner on such a program will accelerate a plan’s ability to make the changes necessary to hit its health equity metrics.
CMS is changing course in how they are weighting the Consumer Assessment of Healthcare Providers and Systems (CAHPS®)* measures to better align with other CMS quality programs. This will redistribute the contribution of these scores across different measures in the Star Ratings program. However, this does not make CAHPS any less critical.
While CAHPS scores will have less overall weight, they are still included in the Improvement Measures and impact the Health Equity Index scores as well.
Deprioritizing CAHPS initiatives can also result in negative member experiences, such as lack of access and services, causing members to leave the plan. On the other hand, positive member experience is correlated with improved health outcomes, medication adherence, participation in preventative care as well as plan retention.
Member experience should NOT be taken any less seriously going forward. Investing in tools to anticipate your members’ needs, potential barriers to care, and who will fall under the Health Equity Index’s determination of vulnerable populations will help improve member experience while boosting other highly-weighted measures.
Utilizing a platform that regularly engages members with their health care will increase the understanding of care barriers, health outcomes, and care gaps insights. It will also allow health plans to take effective action promptly while lowering outreach costs.
In alignment with the Pharmacy Quality Alliance (PQA), CMS is implementing continuous enrollment for several medication adherence measures including Statin Use in Persons with Diabetes (SUPD), Medication Adherence for Diabetes Medication, Medication Adherence for Cholesterol, and Medication Adherence for Hypertension. They are also expanding age criteria for the SUPD measure to include members between 40 and 75.
Additionally, risk adjusted medication adherence measures will move to the CMS Display Page in order to consider the effects of Social Determinants of Health on adherence outcomes in alignment with the findings from the PQA.
Medication Adherence remains a critical component of Star Ratings, not just for the specific medication measures, but also the impact that adherence has on clinical outcomes like A1c and blood pressure.
Maintaining member engagement and contact is also more important than ever. Understanding a member’s medication adherence as close to real-time as possible will be crucial in ensuring member intervention is timely and accurate. Doing so will boost these vital medication adherence metrics, clinical outcomes, and improve a member’s overall experience.
Health plans that add a health equity lens into their medication adherence approach will be better set up for success for these measures. Understanding the sociodemographic characteristics involved in medication non-adherence, and how to intervene appropriately to ensure the same level of health care is available to all members will be important.
Additionally, to effectively move the needle on medication adherence an understanding of human behavior is necessary.
Understanding human behavior and its ties to Social Determinants of Health will help health plans maintain strong adherence ratings. Forging partnerships with proven behavior change programs that are in tune with members’ social needs will better prepare health plans for these important changes.
To better provide care for all members within a health plan, CMS has finalized additional changes that increase accessibility and inclusion for CY 2024.
The list of demographics health plans will be expected to provide culturally competent care for now includes:
Additionally, digital health education must be offered for all members with low digital literacy, so that they may be able to take full advantage of their health plan’s telehealth benefits.
Plans are also expected to expand their provider directories to include cultural and linguistic capabilities, accessibility status for those with physical disabilities, and a provider’s ability to prescribe medications to patients with opioid use disorders.
These changes align with the National Committee for Quality Assurance’s (NCQA) HEDIS direction and roadmap to improve member access and care availability measures.
Demonstrating swift action to accommodate these changes will be integral to a health plan’s equity game plan. It highlights a larger push to ensure equitable care that goes hand in hand with the other measure changes mentioned above. Inclusive language and accessibility will need to ramp up quickly in order to perform well in the Health Equity Index and tackle other measures related to Social Determinants of Health.
Requirements for adequate health care are becoming highly specialized and personalized, which opens the door for innovation opportunities within health plans. Working with proven digital health partners is one way health plans can tap into each member's needs and develop their members' digital literacy. This can ensure that members are receiving the right information, at the right time, through the right mediums.
Between 2022 and 2024, the math to determine Star Ratings is undergoing significant changes. Many of these were solidified in the Final Rule, and other changes are still outstanding with respect to future rule-making clarification.
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Here are additional factors contributing to the shift in category percentages:
These changes all add up to an emphasis on ensuring the best level of care to each individual. That requires a robust health equity plan, highly personalized engagement tools, building strong member relationships, and delivering top-tier health outcomes. The risks of not incorporating these changes are severe, as many plans are expected to see major drops in their Star Ratings AND their Quality Bonus Payments.
Wellth’s motivational behavior change platform helps our partners move the needle on crucial medication adherence measures, care gap closures, improvement measures, health outcomes, member experience, and member retention—both directly and indirectly.
Using Behavioral Economics, machine learning AI, and a keen understanding of the effects of Social Determinants of Health, Wellth helps health plans’ hardest-to-reach members engage with their care plan, improve their digital health literacy, and assist in closing health equity gaps.
With 91% of Wellth members interacting with the app every day, our highly personalized program has helped health plans achieve:
Through behavioral science and live support, Wellth is designed to work through the complexities of human decision making. Wellth’s rewards structure is able to help members work through the cognitive and social barriers that prevent them from following through with their health care.
Digging into Wellth’s rewards spending data, almost 60% of members spend their rewards on food and groceries, while the rest supports other areas of social needs like utilities, transportation, and personal care. Wellth aligns with partner health plans’ outreach and support efforts that will help execute or kick off their Health Equity plan.
By utilizing behavioral science, meeting members where they are at, and supporting their specific needs, Wellth can deliver data-driven improvements to critical Star Measures while ensuring members receive quality care.
“Since I’ve been on this program, I have learned to control my health better than I ever have. It gave me an opportunity to buy all the best food that I need. If it wasn’t for this program, I don’t think I would be able to be on the right track.” - Ruth, Wellth Member.
A large Medicare Advantage plan in Michigan partnered with Wellth to help increase engagement among their hardest-to-reach populations and improve their Star Ratings by improving outcomes and lab values, closing care gaps, and improving overall member experience.
Within one year, Wellth was able to exceed customer targets and saw critical outcome improvements:
This plan achieved a 5-star rating in 2022 and has continued to expand the Wellth program given the success of the partnership.
While many big changes are on the horizon, we are excited to help our partners provide better health outcomes, equity, and quality of care for their members. Wellth can positively impact your Star Ratings goals, and we’d love to show you how!
