In today’s dynamic healthcare landscape, health plan operations need to stabilize and continuously improve to ensure efficiency, effectiveness, and adaptability, especially to secure bonuses for a 4+ Star Rating. Stabilization is essential for large, established health plans to address immediate challenges, such as mitigating risks, resolving operational bottlenecks, and ensuring consistency in service delivery. Without stabilization, our client struggled with member care disruptions, compliance issues, and financial strain.

Continuous improvement is crucial for long-term success, helping health plans stay competitive and on top of industry trends. By incorporating best practices and optimizing processes through technology and innovation, plans can enhance member satisfaction, improve health outcomes, and achieve efficiency gains that contribute to financial sustainability and Star measure performance.

We recently worked with a health plan needing to stabilize operations and prioritize improvement initiatives. They faced high administration costs, siloed performance improvement efforts, and needed to maintain or exceed yearly $288M quality bonuses to enhance services for their substantial membership.

Goal 1: Stabilize operations to become more financially secure

We conducted root cause analyses to identify inefficiencies in operations and strategy. By addressing these issues, we removed bottlenecks to achieve exceptional overall Star Rating.

Strong Medicare Star Ratings are essential for a health plan's stability as they help boost membership and revenue. High ratings also lead to fewer penalties and larger bonuses, which directly enhance the plan’s profitability. Improving Medicare Star Ratings strengthened the health plan’s competitive position and ensured long-term financial health.

Goal 2: Focus clinical improvement efforts to increase quality and improve Star Rating

Together, we worked with our client to create a comprehensive strategic plan aimed at improving and maintaining a high CMS Star Rating. This plan focused on addressing both immediate and long-term goals, enhancing member satisfaction by identifying key areas for improvement and implementing targeted initiatives.

Our collaborative approach ensured that every aspect of the plan was aligned with the health plan's objectives, ultimately leading to sustained excellence and superior member experiences.

Goal 3: Increase revenue

The plan to improve risk score accuracy and quality ratings focused on provider engagement through a targeted, coordinated member assessment program. UST HealthProof’s prospective Provider Engagement Coordination (PEC) program fosters a collaborative environment where providers and health plans work together effectively to achieve common goals and improve the healthcare system.

"Regaining a full star within one year following the loss of a 4 Star Rating demonstrates a swift and effective response to challenges, underscoring the plan's commitment to continuous improvement."

Regaining a full star within one year after a loss of a 4-Star Rating shows a swift and effective response to challenges, underscores the plan’s commitment to continuous improvement. Executing over 20 yearly HEDIS® quality improvement initiatives demonstrates proactive efforts to enhance member outcomes and satisfaction. Achieving 100% HEDIS audit/data submission results emphasizes UST HealthProof’s meticulous attention to detail and adherence to quality standards. These outcomes signify a remarkable turnaround and sustained excellence in Stars and quality performance.

The consistent attainment of a minimum 4-Star Rating for multiple consecutive years showcases a track record of excellence and reliability. Moreover, the estimated $288 million single-year CMS bonuses highlight the significant financial impact of the plan’s stellar performance.

Together, we saw tremendous growth in the Provider Engagement Coordination program, with 2,570 participating providers and a CDI Alert return rate of 76%. This demonstrates extensive engagement and collaboration within the healthcare network and effectiveness in addressing critical clinical issues.

The program's exceptional efficiency and effectiveness in generating significant financial gains is highlighted by achieving a 4:1 return on investment. It also generated an impressive $1.5 billion in CMS program revenue over six years, reflecting significant financial benefits, efficiency, and value.

Overall, these outcomes highlight a dedication to quality care delivery, strategic planning, and improved financial performance, paving the path to financial sustainability.