3 Areas of Innovation to Help Health Plans Conquer CMS Changes
Prepare for CMS's recently issued proposed rule with innovations that impact quality measures.
January 12, 2023

Last month, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule which impacts Medicare Advantage and Part D plans. The nearly 1000-page document contains a bevy of information including prior authorization proposals and marketing restrictions, but notably it illustrates CMS’s continued focus on quality improvement and advancing health equity. Health plans can prepare for these changes and their imminent impact on Star Ratings in years to come by implementing innovative solutions that directly impact quality measures. 

There are three focus areas for health plans that can address the challenges of reaching the hardest-to-reach members, improving health outcomes, and positively impacting quality measures affected by the new CMS proposals:

  1. Increasing medication adherence
  2. Enhancing member engagement and experience
  3. Building an actionable health equity plan

Keeping a pulse on medication adherence

In the CMS proposed changes, measurement year (MY) 2024 will introduce significant changes to medication adherence. These changes present an opportunity for health plans to innovate ways to keep a pulse on daily medication adherence rather than waiting for claims data to come in. 

For MY 2024, CMS is addressing additional pharmacy measures including the concurrent use of benzodiazepines and opioids for seniors, applying continuous enrollment criteria to the 3x weighted medication adherence measures, and risk adjusting for socio demographic status (SDS). Being able to track daily medication usage and adherence patterns can flag any potential risk regarding what medications members are taking concurrently, as well as being able to track medication adherence even during hospital or skilled nursing facility stays. By incorporating daily check-ins for medication adherence, health plans can intervene closer to real-time in cases of non-adherence. 

Medication reconciliation is one component of the Transitions of Care measure reinstated for MY 2022. The return of the All-Cause Readmission measure highlights the importance of staying on top of medication adherence and motivating your members to get engaged and remain engaged, even outside of the hospital setting. 

Wellth, a digital health platform centered on empowering people to make healthy behavior changes, helps motivate members to engage with their health plans by sending nudges for the member to complete care tasks, including taking medications. Using photos to submit these check-ins allows Wellth’s support to work with care teams to flag any concerns about dosage or non-adherence and keep members healthy and on track. These daily touch points have helped our partners boost medication adherence metrics for their highest-risk populations and effectively lowered readmissions related to medication non-adherence.

Fine-tuning the member experience and engagement

While patient access and experience measures will be reduced to a 2x weight rather than a 4x weight in MY 2024, it continues to be of utmost importance that health plans pay attention to the member experience. This change is meant to encourage health plans to think more holistically on how to marry the member experience with delivering high-quality care to effectively close care gaps. CMS is encouraging health plans to look to innovative programs that will engage and motivate members. 

Engaging previously unengaged members requires motivation and building trust. Wellth applies principles of behavioral economics by endowing a certain amount of rewards at the top of a program just for signing up. However, to keep these rewards they must check in with their daily care tasks, like checking glucose, blood pressure, eating a healthy meal, and more. Rewards help capture the attention of members who wouldn’t normally engage with their health plans and emphasizes a small daily behavior change rather than a health regimen overhaul. By going out of the way to incentivize this daily behavior, health plans show their members they are willing to invest in their health and establish trust through daily check-ins and support. 

Once a rapport is built between a health plan and a member, it is much easier to reach the member about other areas concerning care gaps. If members are used to consistent and positive outreach on behalf of their health plans, they are more responsive to surveys or nudges for additional health screenings. 

In anticipation of these additions and adjustments, health plans can assess how they are consistently engaging with members and build reminders, member education tools, and incentives into those capabilities. Wellth does this through habit-coupling. Members who consistently improve their engagement through daily check-ins receive additional nudges to help close care gaps, acquire survey and demographic data, and share educational materials. In receiving this information from a platform they interact with regularly, it builds trust and understanding of how these additional screenings and surveys will help improve their overall health. 

Innovation is required to successfully monitor and encourage member behaviors similar to how social media uses machine learning technology to target specific ads to their customers. Behavioral learning through digital health platforms can help pinpoint the right time, nudge, and motivation to address and close these crucial care gaps while meeting quality measures. 

Build an actionable health equity plan

Through quality-focused proposed changes, CMS is shining a spotlight on health equity. It has been a topic trending in healthcare circles for a few years now, and there have been additions to data reporting, care practices, quality metrics, and federal bills to promote health equity. CMS will be replacing the Reward Factor with the Health Equity Index beginning MY 2025 to incentivize plans to reduce health disparities and encourage forging stronger relationships with their most vulnerable populations. 

CMS and the National Committee for Quality Assurance (NCQA™) have implemented measures to encourage data collection around race and ethnicity, social determinants of health, and barriers to care access. The next step is creating an action plan for this data. Health plans can innovate to engage these members and build that crucial relationship to meet them where they are. 

The capabilities of digital health improve the ability to address language barriers in healthcare and offer solutions and services for certain social determinants of health. However, some concern remains around access to digital tools as well as digital literacy among seniors. While the number of people over 65 who own a smartphone continues to grow exponentially year after year and federal programs are in place to provide smartphones to people with low incomes, programs geared toward digital novices need to be simple, easy to use and easy to learn—with the capability for live support and troubleshooting. 

With a member population ranging from 16 to 90+ years old, Wellth has successfully onboarded and engaged members with a range of digital literacy and capabilities by utilizing a live member support team and a simple interface that requires little user manipulation outside of taking a photo. When additional prompts are incorporated, instructions to complete these tasks or surveys are easy and intuitive.

Effectively addressing health equity and assisting vulnerable populations requires specialized tactics that meet members where they are. There are reasons members tend to be less engaged, whether it is economic struggles, a history of distrust, or language barriers. Understanding why these gaps exist can help health plans innovate to address them. Once trust is built and members regularly engage, it is easier to seamlessly incorporate demographic surveys and receive accurate and crucial data on social care gaps.

One area plans can get creative in engaging hard-to-reach member populations is by utilizing incentives. When a reward is motivating, timely, and beneficial, it can be a powerful tool for closing health equity gaps. Studies have shown that increased monetary endowments in lower-income communities through micro-financing leads to overall improvements in the socioeconomics of that community. When people in these communities receive small monetary rewards, they spend them on the things they need, such as food, utilities, transportation, and household needs. In this Wellth case study, members spent 57% of their rewards on groceries and food and an additional 14% on household needs and utilities.

The benefits of an innovative incentive program are three-fold. 

  • Getting members motivated to engage in desired, healthy behaviors
  • Maintaining engagement through the continued cue, routine, reward habit building
  • Using member incentives as member investments

Health equity minded innovation is what is going to elevate health plans to address social care gaps beyond data collection. 

What’s next

Innovating with member-centric partnerships creates a robust network of capabilities to stay on top of upcoming measure changes and focuses on the most critical aspect—ensuring even the hardest-to-reach members get the best quality of care. 

Wellth is helping partners meet their members where they are by encouraging daily behavior changes that result in improved health outcomes, utilization reductions, member satisfaction improvement, and health equity gap closures. How can Wellth help your health plan innovate in 2023?