P&C Global Practices: AI, Data, & Cognitive Sciences, Organization & Human Capital, Strategy & Innovation
Client Engagement Overview: Transforming Medicare Performance
A leading national Medicare Advantage (MA) organization—serving millions of seniors across all 50 states—recognized a pivotal opportunity to elevate its performance and deepen its commitment to member well-being. Amid rising pressure on quality ratings and heightened scrutiny around risk adjustment, the organization proactively sought to transform its approach—shifting from volume-based operations to a value-driven model centered on care excellence.
P&C Global was engaged to lead an enterprise-wide transformation aimed at improving care quality, member experiences, and enhancing risk adjustment processes — all while controlling costs and improving patient outcomes. Over a two-year journey, this initiative achieved industry-leading outcomes, positioning the health plan as a top performer in the nation’s most complex payer environment.
Challenge: A Pivotal Moment for Strategic Advancement
At the outset of the engagement, the organization stood at a transformative crossroads—facing an opportunity to recalibrate its performance and elevate outcomes across its Medicare Advantage plans.
- Refocusing on Quality:
Following industry-wide shifts and internal changes, the share of members in 4–Star or higher-rated plans reached 21%, a sharp decline from 87% the prior year. Rather than viewing this solely as a setback, the organization recognized it as a powerful catalyst for renewal—prompting a renewed emphasis on clinical excellence and operational rigor to recapture CMS quality bonuses. - Strengthening Risk Accuracy:
Audit findings surfaced gaps in coding accuracy, consistent with national trends. The organization saw this as an opportunity to modernize its risk adjustment approach, ensuring that member health complexity was more accurately reflected and reimbursed. - Cost and Outcomes Pressure:
The client needed to simultaneously improve care delivery, elevate the member experience, and reduce avoidable healthcare expenditures—all while maintaining compliance and member satisfaction.
The opportunity was clear: elevate quality ratings, optimize risk score accuracy, and drive measurable clinical and financial improvements, while setting a solid foundation for sustainable growth.
Solution: Data-Driven Transformation Anchored in Quality and Execution
P&C Global orchestrated an integrated strategy across its AI, Data, & Cognitive Sciences, Strategy & Innovation, and Organization & Human Capital practices. The transformation emphasized “quality over quantity,” prioritizing care value and outcomes over raw enrollment growth.
Advanced Analytics for Risk Adjustment
To address documentation gaps and coding accuracy, P&C Global deployed AI-powered tools—including Natural Language Processing (NLP) algorithms—to extract undocumented conditions from unstructured clinical data. These innovations:
- Enabled frontline clinicians find potential missed diagnoses and validate documentation efficiently
- Replaced manual coding processes with dynamic, predictive analytics
- Focused on strengthening the plan’s Risk Adjustment Factor (RAF) through improved accuracy
Value-Based Care Expansion
- Expanding provider partnerships that reward quality outcomes
- Providing targeted incentives to regional clinics to close care gaps in diabetes and cancer screening
- Leveraging partnerships to enable proactive interventions like regular HbA1c testing for diabetic members and age-appropriate screenings for seniors
Personalized Member Engagement and In-Home Evaluations
The client launched a multi-channel engagement model focused on relevance, personalization, and accessibility:
- Data-driven, multi-channel outreach with personalized interventions such as personalized coaching and monitoring
- In-home health evaluations to identify additional chronic conditions for care
- Improve the value of personalized care as measured by member sentiment
Organizational Enablement and Service Culture Redesign
P&C Global’s Organization & Human Capital experts helped foster a culture of service excellence and high accountability. This included:
- Customer service training and new digital self-service tools to enhance the experience across touchpoints
- AI-powered chatbots and revamped provider directories to improve member convenience, accuracy, and to simplify the care journey
Outcomes: Elevating Performance to Set a New Industry Standard
Within two years, these efforts propelled the health plan’s quality ratings to benchmark setting status. The results of the transformation were both far-reaching and quantifiable:
- Quality Ratings Soared: 88% of members were enrolled in 4-Star or higher plans—up from just 21% in 2021—reflecting a dramatic turnaround in performance and quality.
- Flagship Plan Upgraded: A major national PPO contract advanced from 3.5 to 4- Stars, reinforcing the organization’s leadership in competitive markets.
- Improved Risk Accuracy: Risk score accuracy increased by 20%, ensuring more appropriate payments for member acuity.
- Significant Cost Efficiencies: $660 million in total annual healthcare savings were achieved in medial cost savings from value-based care initiatives.
- Clinical Advancements: Diabetes management rates improved by 49%, while hospital admissions dropped by 7%, highlighting gains in both prevention and chronic care.
- Lower Member Costs: $114 million in reduced out-of-pocket costs were delivered to members by minimizing emergency visits and avoidable hospitalizations.
- Record-High Member Satisfaction: Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores rose nearly a full star—reaching the highest CMS satisfaction levels to date.
Reflecting on the achievement, a senior executive shared that “Our strong Star Ratings are a result of focused execution and seamless collaboration across our entire company,” crediting an “unwavering… continuous improvement” mindset as the foundation of their success.
As described by a plan leader, “This commitment, coupled with a thoughtful focus on benefits that matter most, enables us to offer members more value and flexibility to help with everyday expenses.”
One organizational leader emphasized the care model’s impact, stating, “Our care coordinators guide patients to the right care at the right time, preventing illness rather than just treating it,” underscoring the strategy’s shift toward proactive, holistic healthcare.
These gains also earned national recognition, including a Quality Improvement Award from the Pharmacy Quality Alliance and a Stevie Award for AI innovation. An independent survey placed the plan among the top five MA organizations nationally for customer satisfaction.
Conclusion: A Blueprint for Medicare Advantage Excellence
What began as a high-risk recovery effort became a national model for Medicare Advantage transformation. By embedding precision analytics, accelerating value-based care, and investing in people-first delivery, P&C Global helped this client achieve a comprehensive performance turnaround.
Today, the plan stands as a benchmark for risk optimization, member engagement, and Stars excellence. Its recovery not only restored revenue but also enabled a renewed focus on preventive care, equity, and long-term sustainability.
Partner with P&C Global to Elevate Your Medicare Advantage Strategy
P&C Global empowers health plans to thrive in the nation’s most competitive payer segment. Our integrated solutions deliver measurable results—transforming quality ratings, clinical outcomes, and financial performance.
