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Closing the gap: supporting improved Star Ratings with in-home care

(Pictured above, Dr. Matthew Shapiro, VP of clinical home care programs at Sharecare, delivers a presentation at the BlueCross BlueShield CareSourcing Advisory Group 2024 Annual Meeting).

Medicare Advantage (MA) plans were projected to receive more than $12.8 billion in quality bonus payments in 2023; however, such plans are expected to receive a greater than $5 billion reduction in quality payments over the next 5 years, while their members grow increasingly socially and medically complex. Payors are tasked to do more with less, taking care of increasingly medically complex members, with smaller bonuses.

While health plans seek out comprehensive strategies in light of these reduced quality bonus payments, I believe the healthcare industry will come to recognize one important truth: Home care is a necessary payor strategy to improve quality performance, for which there is no replacement.

As a practicing hospital-based physician, I always tell my patients, “Your life exists outside the four walls of the hospital,” which is a reality payors must also remember. As surgeon, public health leader, and writer, Atul Gawande explained over a decade ago in the New Yorker, there are crucial factors influencing utilization and poor outcomes that are both only addressable in the home, and only discoverable in the home. Without a presence in the home, health plans are challenged to reach patients before their concerns become critical, while providers also often operate under constraints that limit their ability to close these care gaps.

A third of MA members don’t see their primary care provider annually. For patients who do complete a yearly visit, their increasingly complex needs overwhelm providers who simply do not have enough hours in the day to deliver comprehensive care and recommendations. On average, it’s projected that primary care doctors would need nearly 27 hours per day to deliver the recommended care, according to national guidelines. Finally, even if an MA member does see their PCP, who then recommends the appropriate interventions, 70% will have a health-related social need that may impact their ability to follow that recommendation.

Much of these efforts to improve the quality of care are also predicated on inaccurate and incomplete claims, which often conceal the full reality of our patients’ lives as they often fail to account for social determinants – whether the patient struggles with unreliable housing, a lack of transportation, or inconsistent work schedules. Claims also can’t track undiagnosed depression, or events like the recent death of a partner, or an eviction notice.

As payors grapple with these limitations and make plans to improve their quality performance, close member care gaps, and optimize the utilization of resources, I believe there is no alternative as impactful as caregivers. Their in-home visits provide additional opportunities to connect members with a full array of services, while mitigating risks, and supporting both HEDIS and Stars performance. As I recently shared during a presentation at the BlueCross BlueShield CareSourcing Advisory Group Annual Meeting, payors need caregiver support to understand how health interventions exist within the context of their members’ lives.

Through our home care efforts at Sharecare, I’ve witnessed firsthand just how effectively caregivers can discover hidden barriers to care – and even undiagnosed conditions – while providing the specific support members need while building valuable trust. Caregivers enable providers to learn more about patients who become more likely to disclose issues and improve adherence to care management plans thanks to the trust established between the patient and the frontline caregiver. As health plans look to improve their quality performance, evidence shows implementing proactive in-home care interventions can lead to reduced hospital admissions, improved medication adherence, and better overall health management – making home care a valuable strategy for which there may not be  an equal – or superior – alternative.