Driving Member Engagement and Improving Star Ratings With Rewards Programs Entertainment Corporate Marketing Solutions White Paper
INTRODUCTION In 2003 the Medicare Prescription Drug, Improvement, and Modernization Act established the Medicare Advantage (MA) program (commonly referred to as Part C ) to offer Medicare-eligible enrollees benefits that are at least as rich as traditional Medicare Parts A and B. In return, the health plans receive compensation from the Centers for Medicare and Medicaid Services (CMS) to fund their benefit offerings. In 2012 CMS retooled the payment methods and began cutting back on certain fees for services while offering MA Plans the opportunity to increase their payments through bonuses and rebates through demonstrated quality and customer satisfaction. The Five-Star Quality Rating System, which uses a scale from 0 5, with ratings of 5.0 representing the highest quality, was introduced. This program offers bonuses and rebates to high-performing organizations that achieve at least a 3.0 star rating and negatively impacts those plans that receive less than 3.0 stars. REVENUE IMPACT The financial implications of this new system can be significant. An MA organization s rating is directly related to the bonus it earns 3%, 4% and 5%, matching up with their overall rating. This financial impact of star ratings has created tremendous motivation for MA organizations to explore a variety of methods to improve star ratings. Many models for improvement are aimed at improving specific measurements in the rating system. AN OVERVIEW: KEY LEARNINGS The introduction of a new Five-Star Quality Rating System from the Centers for Medicare and Medicaid Services (CMS) for Medicare Advantage (MA) Plans has resulted in opportunities for high-performing organizations to reap significant financial compensation while underperforming organizations risk fines and other punitive actions. With so much at stake, finding ways to improve or maintain an organization s star rating has become a critical component of every MA Plan s strategic planning. The use of a rewards program to drive member engagement is a proven strategy to improve star ratings. This White Paper generated by the Corporate Marketing Solutions team from Entertainment provides a brief overview of the new Five-Star Quality Rating System and offers recommendations for organizations seeking to develop and implement a rewards program. PAGE 2
HOW STAR RATINGS ARE DETERMINED In total, the Five-Star Quality Ratings System takes into account 32 different measures, arranged into five broad categories that determine an organization s overall star rating. All of these measures are individually graded and several of these measures are given greater weight, which means that those categories have more influence on the final average score than other categories. Driving greater participation in these key measures can help an organization improve its overall star rating and plan quality assessment and benefits from higher bonus payments, more rebates, and the opportunity for five-star plans to market to prospective members throughout the year. STAYING HEALTHY: SCREENINGS, TEST & VACCINES C01 Breast Cancer Screening 1 C02 Colorectal Cancer Screening 1 C03 Annual Flu Vaccine 1 C04 Improving or Maintaining Physical Health 3 C05 Improving or Maintaining Mental Health 3 C06 Monitoring Physical Activity 1 C07 Adult BMI Assessment 1 C08 Special Needs Plan (SNP) Care Management 1 MANAGING CHRONIC CONDITIONS C09 Care for Older Adults Medication Review 1 C10 Care for Older Adults - Functional Status Assessment 1 C11 Care for Older Adults Pain Assessment 1 C12 Osteoporosis Management in Women who had a Fracture 1 C13 Diabetes Care Eye Exam 1 C14 Diabetes Care Kidney Disease Monitoring 1 C15 Diabetes Care Blood Sugar Controlled 3 C16 Controlling Blood Pressure 3 C17 Rheumatoid Arthritis Management 1 C18 Reducing the Risk of Falling 1 C19 Plan All-Cause Readmissions 3 MEMBER EXPERIENCE WITH HEALTH PLAN C20 Getting Needed Care 1.5 C21 Getting Appointments and Care Quickly 1.5 C22 Customer Service 1.5 C23 Rating of Health Care Quality 1.5 C24 Rating of Health Plan 1.5 C25 Care Coordination 1.5 IMPROVEMENT IN HEALTH PLAN PERFORMANCE C26 Complaints about the Health Plan 1.5 C27 Members Choosing to Leave the Plan 1.5 C28 Beneficiary Access and Performance Problems 1 C29 Health Plan Quality Improvement 5 HEALTH PLAN CUSTOMER SERVICE C30 Plan Makes Timely Decisions about Appeals 1.5 C31 Reviewing Appeals Decisions 1.5 C32 Call Center Foreign Language Interpreter and TTY Availability 1.5 MEDICARE PART C REPORT CARD Heavily weighted measures denoted in red. USING REWARDS TO DRIVE CONSUMER BEHAVIOR REWARDS PROGRAMS DRIVE WELLNESS... initiatives among current members INSPIRE... healthier, more active lifestyles STRENGTHEN... cooperation & compliance with CMS GENERATE... long-term cost savings for plan participants & insurers IMPROVE... member retention IMPACT... star ratings As an incentive to drive member participation and engagement in these key, weighted measures, many MA organizations have begun offering their members a variety of rewards and incentives for taking specific actions (i.e., Complete your glaucoma screening and you ll receive a! ). This approach offers multiple benefits to the organization, including greater awareness among members about the importance of taking personal steps to better health, adding high perceived value to being a member, helping differentiate a brand that is focused on member health, and improving the member service experience. Members also benefit from incentives, especially if they are relevant and meaningful to their lifestyle. A major requirement to a successful rewards model is that the individual incentive is compliant to CMS regulations. In addition to receiving the reward itself, the member benefits by taking steps to protect their own health by getting the proper screenings, tests and vaccines that can identify chronic conditions or diagnose potential health issues early. These early detection and prevention activities can ensure members receive the care they need soon enough to avoid future problems. PAGE 3
THE CHALLENGES Building an effective rewards program as an incentive to drive participation in star measurements presents several challenges for organizations. A program with multiple rewards can be a complicated, costly endeavor, difficult to implement and hard to execute. Another hurdle is developing high-value, low per-customer cost incentives that are compelling enough to influence member participation and behavior. Most importantly, organizations must also ensure that their rewards programs are compliant with the strict guidelines established by CMS. Failure to comply with these guidelines can result in substantial penalties and loss of revenue. IMPLEMENTING A REWARDS PROGRAM When developing a rewards program there are several factors that should be considered: Universal Appeal Is there something for every interest? Consistency with Brand Does it drive energy and match corporate values? Cost Effective Does it improve the bottom line, with strong ROI potential? Long Shelf Life Will the reward engage members for the long haul? Can it be reinforced? Ease of Implementation What internal resources are necessary? Where can I get support? How long will it take to implement? Organizations should also establish benchmarks for each measurement to determine the success of their rewards program. These measures of success will vary depending on the specific goals of an organization, but often these benchmarks are built around financial models and establish specific goals related to increases in documented member participation in targeted activities. Increase wellness/hra visits by _% Increase diabetes screenings by _% Increase mammograms by _% EXAMPLES OF CMS GUIDELINES FOR REWARDS PROGRAMS: Each reward item must have a retail value monetary cap not to exceed $15 per item. Aggregate retail value of all reward items offered annually may not exceed $50 in the aggregate on an annual basis per member per year. Must not be offered in the form of cash or other monetary rebates. May be discussed in direct mailings to enrollees (as long as there is no violation of the HIPAA privacy laws). REWARDING WITH SAVINGS Due to the restrictive regulations established by CMS related to rewards (no one incentive with a retail value of more than $15), finding the right incentive is critical. One of the more effective approaches has been the use of relevant discounts and savings opportunities in the form of high-value coupon booklets or online savings. These rewards can include multiple discounts for travel, shopping, events, activities, healthy dining, and entertainment as a reward for completing the measures used in the Five-Star Quality Rating System. PAGE 4
WHY COUPONS ARE A GOOD FIT AGE 65+ 14% more likely to use coupons* 13% more likely to be heavy coupon users (use 12+ coupons within 3 months)* AGE 65-74 13% more likely to use coupons 17% more likely to be heavy coupon users (use 12+ coupons within 3 months) AGE 75+ 14% more likely to use coupons 10% more likely to be heavy coupon users (use 12+ coupons within 3 months) *Compared to US Households Overall SOURCE: Nielsen/Claritas Coupon Usage Past 12 Months, 2012 By offering members savings on things they enjoy bowling, accommodations, travel, shopping, golf, dining MA organizations can encourage members to live a healthier, more active lifestyle, which often has positive mental and physical health implications. These are both heavily weighted measures in the Five-Star Quality Rating System. In addition, offering members savings they can use to enhance their lives and stretch their budgets also helps an MA organization add perceived value to their relationship. All of these benefits can naturally lead to better customer satisfaction and a more positive experience leading to improved survey results and improved member retention also criteria used in the Five-Star Quality Rating System. FINDING THE RIGHT PARTNER The Entertainment Corporate Marketing Solutions team has been driving member engagement for more than 30 years across multiple industries. Over the past five years the Corporate Marketing Solutions team has worked extensively with dozens of health care plans. The primary focus of the health care team at Entertainment is building rewards in Medicare Advantage Plans to inspire healthy living among members, increase payments, bonuses and rebates from CMS, and enhance an MA Plan s star ratings. All Entertainment programs are CMS compliant and are developed to promote health, wellness and prevention activities. DRIVING RESULTS Entertainment has helped a variety of health care clients of varying sizes generate substantial results through the development and implementation of Member Rewards programs. Whether the goal is to influence the behavior of existing membership to improve star ratings, or to generate new members, or to create a competitive advantage by offering current members something that they can t get elsewhere, Entertainment has the experience and expertise to develop a rewards program to accomplish those goals. If you are interested in developing a savings rewards program, Entertainment is an experienced partner that can make it easier to navigate the legal, compliance and financial considerations associated with this process. PAGE 5