By 2030, the baby boomer generation will all be age 65 or older. Approximately 10,000 individuals cross this milestone every day, transitioning from baby boomers to seniors. At the same time, the Medicare Advantage (MA) market has expanded dramatically, with the average beneficiary now choosing from 43 plans—more than double the options available just five years ago. This abundance of choice, while beneficial, has also created challenges for health plans . . . and Medicare advantage nightmares for members.
For members, the overwhelming number of options can make selecting the right plan difficult. For payers, it contributes to a staggering average annual member churn rate of 10 percent. Factors like premium costs, out-of-pocket expenses, access to care services, and higher Star Ratings (CMS’s measure of plan quality and member satisfaction) all drive these shifts. The result? A highly competitive landscape where retaining members is increasingly complex.
Recognizing the opportunities and challenges of this evolving environment, our client approached us with a clear goal: optimize revenues, improve margins, and enhance Star Ratings while reducing compliance risks. With our expertise, we helped them eliminate their Medicare Advantage challenges and turn market pressure into a strategic opportunity for growth.
Over an intensive 18-week engagement, we conducted a comprehensive evaluation of our client’s plan Star ratings to identify, assess, and prioritize opportunities for improvement. Leveraging our proven Medicare Outcomes Acceleration framework, we executed a targeted and strategic approach designed to address key challenges and deliver measurable results. This framework provides a methodical strategy with actionable tactics that enable payers to:
With this rigorous framework guiding our work, we developed an in-depth business case that outlined clear, pragmatic recommendations to maximize opportunities for revenue growth, profit margins, Star rating improvements, and CMS compliance. To enhance the value of these recommendations, we leveraged our suite of IP-as-solution accelerators, delivering tangible proof of outcomes for the opportunities identified.
Once the business case was established, we designed a comprehensive roadmap to address our client’s most critical challenges. This roadmap targeted improvements across four essential pillars: people, processes, data, and technology. By focusing on the highest-impact opportunities first, we enabled incremental progress and sustainable results over time. Key achievements included:
Through this assertive, structured approach, we tackled our client’s Medicare Advantage challenges head-on, providing them with the clarity, tools, and confidence needed to achieve long-term success.
Offer highly personalized member engagement experiences and deliver improved care outcomes.
Strengthen member loyalty and elevate the overall experience, reinforcing their brand’s value.
Maximize revenues through enhanced risk adjustment and Star quality bonuses awarded to 4- and 5-Star plans.
Streamline and automate business and IT processes, cutting administrative overhead while improving operational margins.
Establish a robust, compliant data foundation capable of withstanding CMS oversight, minimizing regulatory risks, and safeguarding revenues and brand reputation.
With our expert guidance, the client has begun transforming their data strategy, focusing on building a reliable infrastructure. This foundation will empower them to elevate stakeholder experiences, enhance revenue streams, ensure compliance, and optimize margin performance. Our actionable insights are driving measurable progress, positioning the client as a leader in delivering member-centric healthcare solutions.
