The collection of data for Medicare’s new Health Equity Index (HEI) reward began at the start of 2024. Medicare announced in the Final Call letter of 2023 that it was replacing the Medicare Stars current reward factor with the HEI reward, which measures performance in a subset of Star measures for members with social risk factors (SRFs).
Medicare has defined the SRF population as beneficiaries qualifying for the Part D low-income subsidy (LIS), Medicare and Medicaid (Dual Eligibles), and Disability. While CMS has not announced which measures will be included, experts agree that the three triple weighted adherence measures will most likely be part of the reward calculation.
Prior to this change from CMS, Medicare Advantage plans were already focused on the DE and LIS populations, and there are multiple studies and articles on potential interventions to improve their care. In contrast, a review of studies on care for disabled Medicare beneficiaries suggests there is very limited research for this high-risk population.
Now, there is an opportunity for Medicare Advantage plans to dig deeper and identify underperforming populations, such as those who meet Medicare’s definition of disabled to improve care for beneficiaries with SRFs – and to benefit from the targeted efforts to help their members.
The Hidden, High-Risk Beneficiaries
An often-overlooked subset of this high-risk SRF population is beneficiaries that qualify for Medicare through disability who are typically under 65. According to data from the Social Security Administration, 11 million Americans ages 18-64 qualified for Social Security or SSI benefits due to disability, of which 7.7 million enrolled in Medicare. People younger than 65 make up about 1 in 8 Medicare beneficiaries, according to the latest report from the Medicare Payment Advisory Commission. What’s even more significant is that they require a disproportionate amount of care — accounting for more than 17% of all Medicare spending.
The Diagnosis May Differ for Disabled Medicare Population
Most beneficiaries qualifying for Medicare as Disabled have a physical disability diagnosis. However, the second highest diagnosis is cognitive impairment. Based on CMS data from 2022, 42% of disabled Medicare beneficiaries qualified due to a cognitive impairment diagnosis. Chart 1 identifies the top diagnosis categories for disabled Medicare beneficiaries from a 2022 SSI Annual Report.
As a reflection of those disability diagnosis, a 2023 KFF report found younger beneficiaries are more likely than traditional Medicare enrollees to have lower incomes, education levels, and overall health scores and to have experienced worse access to care, more cost concerns, and lower satisfaction with their care. Not surprisingly, the results of the study also indicated that this population self-reports more difficulty navigating their healthcare experience.
The key takeaway is that this population is unique in age, the complexity of their healthcare needs, and ability to be their best advocates in the fragmented healthcare ecosystem. They experience and engage within the health system differently, and Medicare Advantage plans have not successfully created a benefit that allows them to easily access the care they need. The result, as indicated by their performance against STARs adherence measures, is less optimal outcomes – which now take on increased importance with the HEI reward.
Performance in Adherence Measures for the Disabled Population
With the release of the preliminary medication adherence rates for the 2023 Stars measurement year, Medicare Advantage beneficiaries with a disability performed 3% lower in all three medication adherence measures when compared to non-disability beneficiaries (Chart 2). Adherence rates for beneficiaries with disabilities also performed lower than the average results for the dual-eligibles and low-income subsidy beneficiaries by 3% in the diabetes measure and 1% in the RAS antagonist and statin measures.
The Call to Action and Solution
Health plans must understand how SRFs differ across these three high risk populations to tailor benefits and programs that address the specific barriers for each. Economic challenges like housing and food insecurity could apply across all, but what are the greatest challenges that compromise access to health care for those with physical, cognitive or behavioral impairment. Even once specific risk factors and corresponding programs are developed for the disabled, significant care coordination will be required to resolve issues and improve outcomes for this group.
ActualMeds’ tech-enabled services for Medication Adherence was designed to meet this need and has been serving Medicare Advantage Plans, Prescription Benefit Managers, Provider Groups, and Population Health companies for over 8 years, focused on the highest risk beneficiaries who belong to these populations. The InConcert system identifies complex, high-risk members, along with potential medication risks and other gaps in care and allows our highly skilled team of member care coordinators, nurse care managers, and board-certified clinical pharmacists to provide high-touch services to address any barriers to care they may be experiencing.ActualMeds’ efforts in this area have demonstrated the huge potential to improve outcomes for these groups as shown in Chart 3.
Our approach consistently outperforms industry averages because its system delivers best practice medication management in conjunction with high-touch care coordination services at scale. If your organization is interested in learning more about how ActualMeds can support your Star Ratings or clinical pharmacy programs, please contact us today.