Organizational Restructure and Advanced Analytics Increases Health Plan’s 4-Star Medicare Membership Enrollment by 40%

Situation

A health plan decreased to a 2.8 Medicare star rating with 0% of their membership enrolled in a 4-star plan. The plan required organizational structure changes to support their Medicare stars program and enhanced analytics to ensure organizational goals were met.

Approach

Throughout the first year, AArete created a call-to-action plan that outlined an optimal organizational structure needed to support a successful Medicare stars program. This included measure-owners, measure group owners (e.g., HEDIS, CAHPS, Pharmacy), establishing measure prioritization, and enhancing executive oversight. As part of this call-to-action, AArete assessed and redesigned the HEDIS chart chase process, as well as other processes that impacted measures. Additionally, the new organizational structure facilitated enterprise-wide engagement, visibility, and training.

Results

Through implementation of the comprehensive action plan, an organizational structure to support the Medicare stars program was established. Additionally, AArete delivered advanced contract measure goal setting, enhanced analytics (e.g., member segmentation, forecasting), redesigned provider incentives, and improved operational processes. As a result of these efforts, the health plan eventually had 40% of members enrolled in 4-star plans.