Right Care, Right Time

The future of CAHPS success requires appropriate clinical management at the member level, which translates into better experiences. Care Coordination questions ask if the doctor has medical records, if the member has discussed medications, and if they knew about specialist care. Those are all required components of an annual wellness visit. Annual wellness visits create the interventions that CAHPS Care Coordination measures. Getting Care Quickly asks “When you needed care right away, did you get it as soon as needed?” When members are using the emergency room for non-emergencies, they wait hours. When they use urgent care instead, they are often seen more quickly. Different care setting. Different perception. Different CAHPS response. Getting Needed Care questions assume members are actively seeking care. If they’re not engaged with a primary care provider, they can’t report positive experiences about access. In order to do that, members need help in nudging them to receive appropriate care in the first place.

Approaching CAHPS starts with understanding what member behavior drives positive responses. In order to create positive responses, and experiences, you first need to address member barriers before they turn into negative experiences. Find the barrier. Improve the outcome.

A Regional PPO Takes on Annual Wellness Visits

Knowing that annual wellness visits are a key positive indicator for Care Coordination, that urgent care use could impact Getting Care Quickly and that nudging members towards seeking care would help address Getting Needed Care, a regional PPO plan ran a 2025 program that set out to:

• Educate about annual wellness visits to improve medication reviews, specialist coordination and medical record reviews.
• Refocus ER utilization by re-directing members to more appropriate care settings.
• Improve the relationship between members and their primary care providers.

The Signal Strategy

Since annual wellness visits are not a measure in and of themselves, but drive the performance of multiple other measures, MedOrion’s approach was to focus on finding the barriers to care.

“Annual wellness visits are a strong indicator of the overall health of that individual,” says Dave Burianek, Chief Strategy Officer at MedOrion. “Those that are low utilizers of overall care tend to present with some really complex health issues when they finally do seek care. Increasing annual wellness visits is about getting ahead of future problems down the road. People think, ‘I’m feeling fine. I don’t have time to go in.’ We really need to start breaking down that assumption.”

First, the program targeted members with no annual wellness visits and “low-utilizers,” those defined as having multiple open gaps, minimal prior engagement and sporadic healthcare use. Then, behavioral analysis looked at inputs based on income, language, and access as well as comfort with digital communications. Together they create an individualized profile that targeted the care barriers for each member.

The Results

• An estimated $1.25 million in cost savings.*
• 2992 members completed an annual wellness visit, and there was a 2% increase in primary care visits for the hardest to reach population.
• 1,900 members were redirected away from the emergency room to more appropriate care settings

As member journeys become more clinically complex, getting members to do what you need them to do isn’t just about identifying gaps and moving members to take action. Member engagement success today requires coordination across quality, experience and operations teams that is strongly anchored in organizational priorities and clinical outcomes. The need for high-level coordination also requires a different level of partnership. We understand the challenges of today’s Medicare Advantage market, and work with plans to solve Stars issues at the measure level, freeing you to focus on more strategic priorities, with the confidence that we’ll improve your measure scores and overall Star rating, one member at a time.

*Beckman AL, Becerra AZ, Marcus A, et al. Medicare Annual Wellness Visit Association With Healthcare Quality and Costs. Am J Manag Care. 2019;25(3):e76-e82.

Study finding: 5.7% reduction in total healthcare costs over 11 months following AWV.