Medicare Advantage (MA) plans have a unique opportunity to improve health outcomes, quality metrics, and financial performance by adopting a member-centered approach focused on understanding and addressing the unique needs of each individual. Member-centricity requires that you recognize that what is good for the member is good for business.

Making the business case for the one-touch experience

Members demand and need services that are delivered in a comprehensive and integrated way. To deliver on this, plans must establish clear linkages and integration among operations for risk adjustment, quality, social determinants of health (SDoH), and benefits. For example, a plan could create a comprehensive care team that includes a nurse, a social worker, and a community health worker. This team could work together to address health needs holistically, linking members to plan benefits and services they need, which in turn can drive the accuracy of risk adjustment, improve quality outcomes, address SDoH, and reduce avoidable costs.

Consider integrating analytics across the enterprise

Achieving member-centricity within the Centers for Medicare & Medicaid Services’ (CMS)  emphasis on quality measures and health equity requires new types of creative, integrated analytics. For example, a plan could create a predictive model that uses claims data, electronic health records (EHR), and social determinant data to identify members at high risk of hospitalization or adverse events. By utilizing this model, the plan can identify these members and then engage them with a comprehensive care team that addresses their health needs holistically. Another example is a MA plan could create a patient reported outcome measure (PROM) that captures patient's’ perspective on their health and care received. These analytics could be leveraged across the enterprise to improve operations and to drive interventions to those who can most benefit from them.

Program success hinges on precision

Designing compliant programs that break through silos and incorporate emerging CMS priorities and technical requirements requires more precision than ever. For example, a plan could create a program that serves specific groups of members, such as those with chronic conditions or those whose utilization patterns point to their greater need of health care services. By engaging these specific groups, the plan can design the right engagement and interventions for the right reasons at the right time with different groups of members. This approach super-charges investments in more complex interventions to maximize their effectiveness.

Silo-busting drives operational excellence

Silo-busting involves breaking down the barriers between departments within an organization and encouraging collaboration and communication. By breaking down silos, health plans can ensure that all departments are working together toward the common goal of providing the best possible care for their members. Silo-busting also helps to identify and address areas of inefficiency in an organization, making it easier to spot bottlenecks and areas where it can improve processes. This can lead to more efficient and cost-effective operations, enabling more streamlined care for members. Another benefit of silo-busting is that it can help to foster a culture of continuous improvement by creating an environment where employees are more likely to share ideas and work together to find ways to improve processes and procedures. 

Final thoughts

Adopting a member-centered approach can seem easier said than done. It requires organizational commitment and perseverance. If you're tasked with transforming your program to withstand the headwinds ahead, gather as much info as you can from leaders throughout the industry. Attend webinars and conferences++ ) and network with the experts. Getting this right is more critical than ever and can lead to improved care, more efficient operations, and ultimately to better outcomes for everyone.

RISE National 2023

Want to learn more? Join RISE National 2023 for a preconference workshop on creating member-centered health plans: Innovations to future-proof your success,  12 p.m. to 4 p.m. Monday, March 6 at The Broadmoor Resort in Colorado Springs, prior to the main conference March 7-8.

Article author Ana Handshuh, principal, Cat5 Strategies and chair of the RISE Quality & Revenue Community, pictured right, will lead the workshop along with the following risk adjustment and quality experts:

  • John Criswell, founder, CEO, chairman, Porter
  • Melissa Smith, EVP, consulting & professional services, Healthmine
  • Dr. Shannon Decker, principal, VBC One
  • Liz Haynes, DVP, risk adjustment & stars-government programs, Blue Cross and Blue Shield of Kansas City
  • Daphne Klausner, plan president, Honest Medical Group
  • Alyson Spencer, senior director, clinical quality, Blue Shield California
  • Ally Thomas, Ph.D., AVP, quality improvement, UPMC Health Plan