Improving Medicare Advantage Star Ratings Utilizing Telehealth

Sylvia Romm, MD, MPH, Vice President of Clinical Transformation, American Well


Many players in our healthcare system want to improve care for Americans over the age of 65. Increasingly, these attempts have come through expansion in the number and size of Medicare Advantage (MA) plans. Since 2010, enrollments for Medicare Advantage plans have grown by 71 percent. Today, 33 percent of Medicare beneficiaries—or 19 million people—are enrolled in a Medicare Advantage plan.

With the growing popularity of MA plans, private payers are finding the market increasingly competitive for attracting new enrollees and increasing revenue. Each year, the Centers for Medicare & Medicaid Services (CMS) releases 5-star ratings for each private payer MA plan and plans show increased or decreased enrollment in their plans based on how well they do within the CMS Star Ratings System. The ratings are based upon plan performance in five key areas:

  1. Staying Healthy: Screening, Tests, Vaccines
  2. Managing Chronic Conditions
  3. Member Experience with Health Plan
  4. Health Plan Member Complaints and Appeals
  5. Health Plan’s Customer Service

Not only do these star ratings impact enrollment in MA plans, they also determine per member per month (PMPM) rates by Medicare. Plans that earn at least four stars receive a five percent bonus to their monthly PMPMs, while plans with lower than four stars receive no bonus. 

A recent analysis found that a 1-star improvement could lead to an eight to 12 percent increase in enrollments, and improving from a 3-star to 4-star rating could increase revenue by 13-17 percent.

Telehealth could help health plans improve CMS star ratings by actively engaging members and delivering better, more frequent care. Of the five areas of the CMS Star Rating System, three could be directly improved via telehealth, while the other two have indirect benefits. The three that could be directly improved are:


Staying Healthy: Screening, Tests, Vaccines

This star is based on whether members receive necessary screening tests, vaccines, and other tests to help them stay healthy. While you can’t give a vaccine or do imaging or labs during a telemedicine appointment, a plan or provider can proactively schedule video check-ins with members who have not had vaccines or screenings to counsel them, answer their questions, potentially order the appropriate lab/imaging/medication, and ensure they do take that next step. For example, a member who has not had a breast cancer screening can be engaged via a video visit where a provider answers questions about mammograms and helps them fulfill the requirement. 

While the actual star is rewarded for the completion of these screening and vaccines, engaging the member is often the hardest part. Once you have engaged members and helped them understand what they need to do, they are more likely to complete the necessary steps to obtain appropriate care. 


Managing Chronic Conditions

Receiving a star for managing chronic conditions requires that members obtain the recommended tests and treatments associated with their chronic condition. Telehealth is used extensively for chronic disease management across the healthcare ecosystem, including to help manage members with COPD, diabetes, cystic fibrosis and cancer. By having frequent video check-ins with members who have chronic illnesses, plans can provide a low-barrier way for members to make sure they’re staying on track with their treatment. Telehealth can be used for medication management, counselling or check-ins. Not only are video visits more convenient for members with chronic illnesses, they produce high satisfaction rates when members do not have to travel long distances for specialty care.


Member Experience with Health Plan

Members’ self-reported ratings of the plan are the measures reported for this star. Do your members feel that their experience is a good one? Are they, for example, getting needed care or getting appointments and care quickly?

Telehealth can help MA plans maintain and even increase member satisfaction. A recent study by Southwest Medical Associates, a wholly-owned subsidiary of UnitedHealth Group and Optum, not only found that patient diagnosis via telehealth were effective, but that telehealth produced higher patient satisfaction rates. The study, which looked at the treatment of upper respiratory tract infections, found that patients diagnosed virtually had a 45 percent reduced chance of needing follow-up care within two weeks. There was also a higher patient satisfaction rate for virtual visits (95 percent) compared to in-person visits (84 percent).

Improving member engagement can have a far-reaching effect on the CMS Star Rating, from improved member satisfaction to increased compliance with appropriate health maintenance measures. Telehealth’s benefits can also extend beyond the ones directly measured by the CMS Star Ratings System. For example, innovative commercial plans have begun to use virtual visits to extend needed behavioral health services into member communities, to engage local providers in a collaborative care model, and to reduce unnecessary ER costs. Decreasing barriers to appropriate care with telemedicine is a cost effective way to improve care and improve member experiences. Click here to learn more about how your health plan can best utilize telehealth to engage your members.