In meeting the complex needs of the socially weak population, including low-income people with colored and those with disabilities, is one of the most urgent challenges for Medicare Advantage plans (MA), especially qualifying special needs plans (D-SNPs). However, the truth remains that people who live in socially weak societies are less likely to reach high -classified MA plans due to:
- High rates of poverty and unemployment, which can lead to high health care costs that make the risk to serve these societies
- Lack of primary care doctors and specialists
- High rates of chronic diseases, mental health conditions, and factors such as food insecurity
Since plans that earn less than four stars are not eligible to obtain reward payments from Medicare & Medicaid (CMS) service centers, low -rated plans have less resources to invest in strategies to address the social risk factors (SRFS) aspects of inequality. Their main challenges include:
- Resources restrictions. MA plans in low -income areas often contain lower resources to address the social health determinants (SDOH) such as unstable housing, lack of access to nutritious food Healthy behaviors.
- Complex health needs. Individuals in low -income neighborhoods are likely to suffer from chronic diseases such as diabetes and high blood pressure.
- Communication barrier. Anguage barriers, low health literacy, and limited access to technology can impeding communication between organs, which ultimately affects health results and dozens of quality.
Preparation for the Health Rights Index 2027
Another factor that can create additional challenges for plans that seek to obtain higher assessments, which is the health stock index (HEI). Since 2022, Hides® The degrees of health effectiveness and information group (HEDIS) have decreased between MA plans with higher proportions than dual violations with special needs, which cover the most socially weak population. With the introduction of Hei, which includes many Hedis® Pharmacy measures, CMS aims to reflect this late performance and stimulate plans to reduce sponsorship variations, all with more than $ 5 billion in savings over a decade.
Hei replaces the reward factor in the year of measurement 2025 to influence the classifications of 2027 stars. While the bonuses factors benefit from high and fixed plans, Hei Rewards plans with high -level degrees for members who have specific SRFS. Like a bonus factor, HEI adds up to 0.4 stars to the star classification of the total contract, which means that some plans can gain or lose up to half a star based on their health stock strategies alone.
Improving stars classifications and improving gaps in care
By introducing Hei, plans that give priority to long -term strategies to support the population at risk will be better performance on quality standards as well as higher assessments. Below are some of the ways that the leaders of the health plan can behave now.
Set the goals with predictive cut points. More than half of the cut points increased from 2024 to 2025. With CMS systematic changes, the cutting points will continue in the upper direction, and the plans will need to set higher goals only to maintain the same classification. The plans should follow their performance using tools that can predict the cut points for the coming years; Otherwise, it can be less than their goals.
Figure 2. Cutting points trends: compared to 2024 stars classifications to 2025 stars.
Select the members who suffer from SDOH using social, economic and pirate data and demands. Health Risk Assessments (HRAS) and other organ reactors can use SRFS and capture as ICD-10 Z drawings (Z55-Z65). Plans can also use census data at the neighborhood level to identify potential vulnerable members. Then they can target their awareness plans, registration of members of low -income programs, and provide individual support.
Cooperation with local organizations to provide society’s benefits. By communicating with community health centers and social services agencies, plans can provide housing, food and transportation.
Emphasizing preventive care and early intervention to reduce the occurrence of chronic diseases and complications. Plans must provide wellness programs, health education and preventive offers to encourage health behaviors and early health issues.
Commitment to difficult work in the future
While strategies to address health inequality require planning, partnerships and investments, they are necessary for plans to bridge gaps in care and survival competitive. The plans that are behaving now will be graceful for continuous policy changes in a better position to achieve higher assessments and provide better care for their patients.
Marj Siasita He is the director of the product in the star of the star in Cotiviti and Lea Dewey, Mail per hourand He is the vice president of clinical and consumer operations in Cotiviti.