Real-time Data Key to improving Medicare Advantage Star Ratings, Closing Care Gaps
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Medicare Advantage plans are increasingly focused on swiftly addressing gaps in patient care, but a critical oversight-inefficient transitions of care-is hindering their progress. According to industry analysis, these transitions represent the most frequent breakdown in care coordination and offer the greatest potential for improving quality measures.
A growing emphasis from the Centers for Medicare & Medicaid Services (CMS) and the Healthcare Effectiveness Data and Facts set (HEDIS) is placing a premium on time-critical interventions, particularly during pivotal moments in a patient’s journey. For instance, the FMC HEDIS measure now mandates follow-up within seven days of an emergency department visit for patients managing multiple chronic conditions.
Four Measures Driving Star Rating Improvements
Four specific HEDIS Transitions of Care (TRC) measures are now weighted three times more heavily in Star Ratings calculations after their initial year of implementation:
- Notification of inpatient admission
- Receipt of discharge information
- Medication reconciliation post-discharge
- Patient engagement after inpatient discharge
Without access to timely data, health plans struggle to effectively report on and respond to these measures. In fact, the national average for meeting the “receipt of discharge information” measure stood at a mere 23% in 2024, highlighting a meaningful area for enhancement.
Effective coordination following hospital discharge yields a compounding effect, leading to improved medication adherence, closure of chronic care gaps, and increased member engagement that can disrupt recurring patterns of healthcare utilization. “One operational improvement can have multiple measure impacts,” a senior official stated.
The Challenge of Delayed Data
A major obstacle for many health plans remains their reliance on delayed census and claims data, which can lag by one to three weeks. This timeframe is simply too slow to address measures requiring action within days. When critical information regarding discharges, medication changes, or emergency department visits arrives weeks after the event, care managers are left reacting to complications rather than preventing them. Manual workflows and fragmented data further complicate matters, hindering collaboration and timely intervention between payers and providers.
Collaboration and Real-Time visibility are Essential
Efficient collaboration between health plans and providers is paramount. Both entities require seamless communication and data visibility to effectively close care gaps and improve Star Ratings. However, outdated reports, reliance on phone calls, and the prevalence of disparate electronic health records (EHRs) often impede this crucial exchange.
The need for real-time data is becoming increasingly urgent. Patients are most receptive to behavioral changes immediately following a care event, creating a narrow window of opportunity. Systems that trigger action in real time, rather than weeks later when claims data becomes available, are essential.For example, documentation of inpatient admission must be sent to a member’s primary care physician within three days, a requirement often impossible to meet with current data delays. The consequence? Lower Star Ratings and lost opportunities for quality improvement.
The Bottom Line: Patient Outcomes and Financial stability
Closing care gaps is not solely about regulatory compliance; it’s fundamentally about delivering better outcomes for patients and safeguarding the financial stability of health plans. The challenge is clear: health plans must transition away from outdated data and manual processes to achieve real-time collaboration.
How can health plans overcome these obstacles? Further analysis, planned for release in Part 3, will reveal how health information technology is transforming care coordination and driving tangible results.
Timely collaboration is the key to higher Star Ratings. See how PointClickCare connects plans and providers to act on care gaps at pointclickcare.com.
