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Abstract

There are ample approaches to improving CMS Star Ratings. However, they can fall flat when there is no tool to make care gaps explicit and seize golden opportunities as they arise when interacting with members. Our client was struggling with how to equip their Medicare Advantage Customer Service Advocates (CSAs) to engage members with just the right topic at just the right time.

By implementing the Stars Gap Board, the client was able to improve the member experience and quality of care, empower their CSAs to take decisive action, as well as have access to a configurable architecture, at a low maintenance cost, which could be implemented to other business lines.

As one of the top four Blue Cross and Blue Shield-affiliated insurers, this health plan has numerous diversified businesses and operates health insurance plans in three states, serving over five million members.

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The Challenge

Star Ratings have an express impact on a payer. CMS will financially reward or penalize plans based on their ratings, and, because the ratings are consumer-facing, they can potentially sway customers to choose or avoid a particular health plan.

Addressing care gaps – like preventive care appointments, medication adherence – can be difficult to detect and address at pivotal times when customer service is actively engaging members.

Our health plan client needed a way for their member advocates to have Star Rating-related measure data at hand and be able to see data flagged, indicating possible care gaps.

Even trickier was the need to tailor the platform to address special Medicare and ACA circumstances like when a child stays on their parent’s insurance until the age of 26.

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The Solution

The Stars Gap Board is an application that allows Medicare Advantage Customer Service Advocates (CSAs) to identify and drive Stars-related conversations with members to close care gaps.  The application features a comprehensive dashboard that consists of a gap summary, key member information, measure category, calls to action, history status, discussion history, discussion updates, and reporting.

The Stars Gap Board includes an executive dashboard of key metrics that helps leadership see how advocates are performing related to Stars measurements and addressing care gaps.

Also, it uses a web-based interface and business logic, delivering relevant data at just the right time for the right member.

SDLC Stars Gap Board AppKey Features:

  • Provides member information on Gap Summary Screens, including history and status, as well as reference information and verbal scripts to help as “calls to action” for the member
  • Ability to search a directory of health care providers within a member’s network
  • View and update discussion history
  • Enables view of gaps discussed and dispositions by pie chart or table and scheduled appointments/follow-ups
  • Quickly capture call information through intuitive interface
  • Automatically load changes to program information and eligibility, displaying real-time content
  • Back-end tables are being re-purposed for additional applications and needs in other areas of the organization

Implementation Details

  • Modern UI Technologies – AngularJS can be built on top of existing technology stack
  • Beautiful, clean code – Easy maintenance and ability to build further enhancements
  • Configuration-based architecture – Changes to programs and eligibility loaded automatically from metadata
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The Results

Not only was this project up and running within an aggressive 14-week timeframe from inception to implementation, but the CSAs were able to start addressing care gaps with members in ample time before that year’s member communication black-out period.

CSAs were able to quickly identify care gaps and easily drive Stars-related conversations with members using the most up-to-date program information. This helped them to build rapport with members and be knowledgeable about that member with timely ideas and needs. Overall, the application allowed CSAs to improve member experience and quality of care; positively impacting Stars ratings.

As more health plans look for ways to close care gaps and utilize timely data to engage members, the Stars Gap Board is the right solution to accomplish both. Now, member services can address just the right need with the member at the most opportune time.

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