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Medicare Advantage is a large growth area where revenue opportunity abounds. Wondering what may be keeping your organization from achieving success with Medicare Advantage STAR ratings? It’s your member experience, starting with how your members access quality healthcare.
To reach the full potential of your STAR ratings, certain fundamental challenges must be addressed in your organization to ensure access to quality healthcare, or more emphatically, access to physicians that are qualified to treat your members’ specific needs on a case-by-case basis.
Seeing the wrong physician can quickly lead to incorrect treatment plans, unnecessary procedures, misunderstanding of diagnosis and other preventable medical errors.
Access is Everything.
Access to quality healthcare is one of the largest issues facing member experience today. The problem is fundamental and starts with provider directories. Even if they were 100% accurate and up-to-date (which they are not), they are inherently inadequate.
Why are your members so frustrated?
1. Members cannot discern which physician is best for their situation from a one-dimensional provider directory, regardless of the sophistication of the lookup interface. For many conditions, a directory search will yield dozens of physicians.
2. Provider directories are based on credentialing and contract data, not the data required to objectively evaluate the entire profile of physicians, including their area of specific clinical expertise, experience, compliance, and outcomes.
3. There is zero matching intelligence that factors in the specific condition of the member and the broad array of social determinants, preferences and logistical practicalities which are critical to the member’s ability to get access to timely, affordable and effective care.
4. Given the constraint of your provider directory, personnel from your plan, such as care managers or advocates, are not equipped to provide specific recommendations to members about which doctors they should see and where to see them.
5. Members become frustrated with the time and effort to find doctors that can meet their needs. Even if they find their way to a physician, members may not have confidence in their treatment plan because they weren’t given a choice of qualified physicians matched to their specific diagnosis.Members may receive referrals to appropriate doctors, but is the recommended physician accepting new patients? Do they have appointment availability in line with the acuity of the condition? Are you sure they accept your insurance?
The Impact of the Lack of Access to Quality Healthcare.
Failure to provide proper matching to the right healthcare provider and facility could result in:
- Member dissatisfaction
- Incorrect treatment plans
- Unnecessary plan utilization
- Preventable medical errors
Solving the Healthcare Access Dilemma.
Fortunately, when it comes to solving access to quality healthcare, there are solutions to these challenges that are available today and integrate with existing processes and workflows. Here are a few.
1. Incorporate technology-based programs that make objective, data-driven recommendations with a concierge touch to help your members access the right doctor the first time:
A. Direct member access to recommendations online or by phone.
B. Empower customer service, care managers or advocates with ability to initiate concierge-style recommendations on behalf of the member.
C. Provide members with recommendations of vetted, quality physicians who also assure appropriate appointment availability and provide prerequisite visit requirements.
2. Replace the “Search and Pray” method of finding a new physician (i.e. search for a doctor online and pray that they’re good) with objective recommendations for highly qualified physicians that are the best fit for the member.
3. Fix the matching problem and enable cost-effective access to quality care that is the most appropriate for the member and is aligned with all the precepts of value-based care.
Better STARS are in sight with a few improvements to how members access quality healthcare. Provide the level of service that your members have come to expect from your organization. By making changes to provide a better experience to your members and how they obtain care, you’ll see member frustration decline and member satisfaction soar.
For more details about how we help you solve the STARS challenge, download this solution guide: Overview for Health Plans or contact me by email or phone.
Connect with me at booth #1327 at The Blue Cross Blue Shield Summit in Grapevine, TX, April 30th - May 1st.