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.