Intelligent provider engagement for health plans to move the needle on Star Ratings and Quality Performance
By: Amy Goodman and Zachary O’Neil
· A patient calls her PCP office to reschedule her annual physical and is told the next available appointment is not for seven months.
· A patient newly diagnosed with diabetes struggles to manage changes to diet and exercise to control H1Ac.
· A patient is discharged from an acute setting into SNF and finds himself needing to repeat full medical history and receiving contradictory treatment protocol in his first interactions at the SNF.
What do these three scenarios have in common? They’re just three examples of the 26 CMS Star Rating measures that encourage Medicare Advantage (MA) health plans to ensure high-quality care, but where the responsibility of care delivery sits directly with providers.
Star Ratings are critical performance indicators for MA plans as a reflection of their high-quality care and as a core sales and marketing beacon to attract and retain members. They also represent significant financial opportunity, with the move from 3.5 to 4 Stars representing upward of $110M for an MA plan with 200,000 members.[1]
While today’s example focuses on Stars performance, effective provider engagement is equally critical to enable quality performance in managed Medicaid and commercial lines of business.
Health plans and legacy vendors both invest significant resources to partner with providers to improve performance on these core quality measures. However, many current approaches fall short. For example, a Medicare Advantage plan and its NCQA HEDIS vendor might calculate point-in-time care gaps based on claims available and send a static list to the provider’s secure portal. Meanwhile, that same provider office may be receiving multiple digital, telephonic or live outreaches on topics ranging from contract performance to claims payment to enablement tools — all within the same week from the same health plan.
A better way
Best-in-class provider partnership models require health plans to deploy several interdependent programs and capabilities. All elements of the best-in-class model need to be deployed in coordination to drive the desired outcomes. We find that tactical considerations to push last-mile provider engagement are often the missing link in health plans’ broader provider partnership strategy.
FIGURE 1: Best-in-class provider partnership models require health plans to deploy several interdependent programs and capabilities
ZS partners with health plans for last-mile delivery of effective provider engagement. Our approach improves response rates by defining and delivering the next best actions for each provider’s office and personalized content and channel outreach to meet their needs. We also reduce administrative costs by helping our clients do more with less, while targeting engagement resources at the most significant opportunity.
In the future state, the office administrator and physician leaders of a provider group that is prioritized for outreach would receive a coordinated sequence of nudges and enablement support to help that group address priority care gaps. Calls to action would be coordinated across the portal, phone and face-to-face interactions of different health plan stakeholders. Communications would align with the specific contracted incentives and enablement support deployed for that provider group.
Our approach
FIGURE 2: ZS’s Intelligent engagement approach
Our intelligent engagement approach is built off of (1) comprehensive insights through any integrated data platform, (2) turnkey and advanced analytics and (3) the ZAIDYN™ Orchestration Engine (Part of ZAIDYNTM Customer Engagement suite) honed through decades of experience helping clients effectively engage with providers.
1. Integrated data platform: We equip health plans with third-party data insights to deepen their understanding of market dynamics and key provider performance attributes. Through our FHIR interop platform, we combine health plan claims, operational and clinical data allowing us to access a rich base of performance intelligence that becomes the foundation of insights and action.
2. Turnkey and custom analytics: We characterize provider groups based on the level of unrealized opportunity for the health plan to engage and that health plan’s ability to influence the provider. This approach lets health plans prioritize the highest impact resources — such as face-to-face engagement and investment in enablement support — where they can have the greatest impact.
FIGURE 3: We prioritize healthcare organizations (HCOs) based on the level of unrealized opportunity and the health plan’s ability to influence
In addition, we layer advanced analytics and AI techniques to predict member-level care gaps and empower providers with the intelligence to proactively intervene. AI models to learn the drivers of care gaps based on historical patterns and inform a prescriptive intervention strategy.
3) ZAIDYN™ Customer Engagement’s last-mile delivery orchestration engine delivers targeted content through preferred channels and delivery mechanisms. It deploys personalization algorithms, learning from historic health plan engagement data, including KPIs of specific campaigns, to target and deploy next best actions for each provider group. It improves the effectiveness of last mile engagement through several dimensions:
Personalize the outreach (channel, content) based on what we know about the provider’s profile and preferences, rather than a one-size-fits- all approach
Harmonize the different channels of communication to ensure a consistent focus and message as well as optimal sequencing to reinforce the message, rather than an uncoordinated approach
Adapt the outreach as we gain more information about the provider, including care gap performance and engagement with previous outreaches
FIGURE 4: ZAIDYN trains itself on prior engagement history to understand the combination of content, channel and cadence to drive impact
The future is now
Health plans can reimagine their provider engagement functions to drive more impact with fewer resources. Whether going all-in with a fully automated orchestration engine or taking a more incremental approach with manual data aggregation and business rules design, it is imperative to improve the last-mile of provider engagement. Effective provider and health plan collaboration is too important for Star Ratings and other essential quality priorities to continue with only current state approaches.
[1] Estimated average $33 PMPM QBP and $14 PMPM rebate opportunity; Commonwealth Fund
