In this three-part blog series, we give MAPD plans the intel they need to improve 2020 Star Ratings and get ahead of 2021 cut points.

In this blog series, we have been discussing how Medicare Advantage Part D (MAPD) plans can improve their Star Ratings by using analytics to get greater control of their future in an uncertain market. Specifically, using analytics on medication use measures (which impact almost 50% of total Star Ratings) in four strategic ways:

  • Identify members in a more intentional way.
  • Refine intervention methods to meet members’ individual needs.
  • Enhance predictive value to inform tactical execution and strategic planning.
  • Impact care delivery by gaining greater control over where and how it happens.

We covered identification and interventions in our last blog post, and here we’ll be focusing on the role of analytics in predictive value and care delivery.

ASK: Are we adapting to changes in care delivery?

Pressure for MAPD plans to improve member outcomes and maintain Star Ratings is happening at the same time that the healthcare industry is experiencing a profound shift in how care is delivered. This disruption – impacting where care happens as well as how care happens – has the potential to position MAPD plans with a competitive advantage. The key is for plans to use analytics to take advantage of care decentralization and the rise of precision medicine.

The Patient-Centric, Decentralization of Care

Where care happens is shifting from inpatient settings to outpatient settings to the patient-centered medical home. This decentralization and task-shifting brings care to lower-cost venues while reducing a patient’s risk of preventable hospital-acquired conditions, such as sepsis or recurrent pneumonia. The goal isn’t a surprise to anyone – the Triple Aim: high-value care that lowers costs and improves outcomes.

Amid this shift, providers are increasingly responsible for what happens beyond the hospital visit or office appointment. Better patient outcomes lead to higher Medicare reimbursements; steady or worsening outcomes lead to penalties. To improve outcomes, providers need to know what’s happening to patients in between episodes of care – where are they making progress, where is there room for improvement, and so on.

MAPD plans are well-positioned to engage with providers to address these needs. Analytics provides plans with insight into which members would benefit from interventions to improve medication use, due to risks ranging from polypharmacy to low health literacy to financial barriers, as well as which types of interventions to prioritize for which members. This can empower providers to take appropriate action to improve patient outcomes, whether through individual action or through a Clinical Pharmacy Program in which pharmacists engage with members. In addition, a plan’s use of analytics can enable providers to create individualized interventions improves the patient experience – a critical concern as providers face increased competition from convenient care options such as retail health and urgent care clinics. 

The Move from “Cookbook Medicine” to Precision Medicine

How care happens is changing as well. Care plans, treatment options, and drug regimens are increasingly customized to the individual needs of patients. These, in turn, are determined based on analyses of multiple data sets – including, but not limited to, clinical, claims, pharma, genomic, publicly available, and patient-generated. This concept is what’s typically called “precision medicine.”

One of precision medicine’s key goals is transitioning care delivery from reaction to prevention – from reacting to the symptoms that a patient presents in the emergency room, for example, to preventing the onset of those symptoms in the first place. Achieving this goal requires direct, individualized interventions – identified and refined through the use of predictive analytics – which address specific care plan objectives, barriers to care, or comorbid chronic conditions.

Precision medicine represents a new way of thinking about care delivery. Providers have been slow to adapt to this change – and this presents MAPD plans with an opportunity. Using predictive analytics, plans can select the direct-to-member interventions that will target a provider’s specific concerns about a member’s historic and projected medication use. Personalized interventions help members manage symptoms and side effects, stop taking unnecessary medications, and avoid preventable complications – all of which improve outcomes and reduce care costs for providers.

ASK: Are we focused on where we’ve been, or where we want to be?

Analytics can do much more than help MAPD plans identify the right members, refine interventions, and impact care delivery options over the Stars performance year. Used properly, analytics can add predictive value, allowing plans to make informed strategic decisions about long-term program structure and to refine tactical execution and investment based on anticipated member behavior. That leads to quality improvements, cost savings, higher Star Ratings, and member retention; it also positions plans for growth as educated consumers base their open enrollment decisions on quality metrics such as Star Ratings.

Overcoming Obstacles to Predictive Analytics

Unfortunately, achieving an ideal analytics structure isn’t simple. Specifically, plans need to take precautions to overcome these three major obstacles to valuable predictive analytics:

  • What it really means. Vendors have been known to oversell offerings they describe as “predictive analytics.” Dashboards, pivot tables, and even AI may not necessarily add predictive value. Make sure you level-set in advance with both internal and external vendor/partner teams around what definitions and terms you’re all using.
  • How to use it. Predictive analytics is not the answer – it’s part of the process that generates the answer. The best predictive analysis uses relevant datasets containing historical information as well as current trends to offer a realistic view of the future, improve a plan of action, and influence day-to-day operations.
  • What data sources to use. Retrospective PDE data simply doesn’t cut it. If you rely primarily on this data, be aware that it overestimates adherence rates at the beginning of the year and provides an unrealistic baseline. What plans really need is adherence data spanning a 12-month period, with both single- and double-fillers, as well as near real-time claims and pharmacy data.

Key Takeaways for MAPD Plan Leaders

The healthcare environment isn’t getting any less complex, and Star Ratings are only going to get more advanced to meet that growing complexity. MAPD plans don’t need to scramble to keep up – you can get ahead and stay ahead with effective quality measure programs. Here’s how to do it:

If you have questions, we have answers. Reach out for a demo, custom strategy plan, or one-on-one conversation about your needs, goals, and budget.