Using the Quintuple Aim to Prep for CMS Star Ratings QI Hold Harmless Provision Changes

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2024 and 2025 are set to be challenging years for Medicare Advantage (MA) plans, thanks to CMS’s extensive proposed changes to the Star Ratings system, ranging from medication therapy management (MTM) to the Health Equity Index (HEI) measure and beyond. Plans will have to juggle a lot of new ideas and initiatives over the next few months if they wish to become—or remain—eligible for Quality Bonus Payment (QBP) incentives.

Among the most high-impact changes is a major anticipated revamp to the Quality Improvement (QI) Hold Harmless provision. Previously, the Hold Harmless provision exempted high-performing 4.0+ Star plans from certain penalties if they fell short on a set of heavily weighted measures.

Now, CMS has proposed to shift the provision,  allowing 5-Star plans only to be “held harmless” from less-than-optimal performance on this set of 5x-weighted Part C and Part D Quality Improvement measures. This could potentially leave hundreds of MA plans at risk of lower scores in the overall Star Ratings methodology. As a result, these plans may miss out on important QBP opportunities, face less favorable marketing rules, and risk losing their position in the consumer marketplace.

MA plans need to improve performance across the relevant QI measures so they can reach the new “held harmless” threshold—but they shouldn’t stop there. They need a comprehensive strategy for overall quality improvement that will help tackle the 5x-weighted behemoths, while also meeting the many other demands of the Star Ratings system.

Thinking about boosting Stars performance holistically, instead of focusing on just one aspect, will enable plans to take advantage of the interconnected nature of the Stars measures and achieve the complementary goals of the Quintuple Aim: improved population health, lower costs, better experiences for members, better experiences for providers and payers, and improved health equity for all.

Exploring the details of the revised QI Hold Harmless provision

A score of 4.0 Stars is highly respectable, but CMS believes the Hold Harmless provision could use an adjustment based on its original intent, to encourage continued improvement across all measures. Within the first final rule issued earlier in 2023, CMS stated, “The original intent of this hold harmless provision was to recognize that higher performing contracts have less room for improvement. Our experience with the Part C and Part D Star Ratings program since this policy was finalized suggest that contracts with 4 or 4.5 Stars for their highest rating still have room for improvement.”

The agency is now looking for creative ways to motivate plans into the closing the gaps, and altering the Hold Harmless provision is one of them.

Quality improvement measures show how much a plan’s performance has improved or declined from one performance year to the next, and both Part C and Part D each have their own QI measure (C25 and D04, respectively). A score of 2.0 Stars or less on one of these measures generally means the plan’s performance has declined over the previous year. Three Stars means neutral performance, while 4.0 to 5 Stars demonstrates notable improvement.

Right now, 4.0+ Star plans can choose how these measures are applied to overall performance for the year. If they get an undesirable score on the QI measures, they can exclude them from their calculations and avoid the statistical penalty from poor QI performance.  Starting in 2024, CMS is planning to change the provision so that only 5-Star plans can take advantage of this flexibility. All other plans must include their 5x-weighted QI scores in their calculations, even if it means dropping them back into lower scoring territory.Article quote

Industry experts believe that between a third to a half of 4.5-Star plans may drop to 4.0 Stars due to the proposed change to the Hold Harmless provision, while a similar number of 4.0- Star plans may slip down to 3.5 Stars.

Combined with additional changes to the scoring methodology, such as the use of the Tukey method for managing outliers and swapping out the current reward factor for the Health Equity Index (HEI) measure, MA plans on the edge of the highest performance categories have a lot to think about in 2024 and beyond.

Plans can no longer rely on these complex statistical factors to “save” their scores, and instead must get to grips with boosting their real-world performance on critical quality objectives, which are encapsulated in the five close-knit goals of the Quintuple Aim.

Leveraging the Quintuple Aim to see success with Hold Harmless and more

Quintuple Aim Pentagon GraphicThe five branches of the Quintuple Aim touch all the important areas of high-quality, affordable, accessible care, and are closely mapped to what the Star Ratings system is ultimately designed to measure.

Plans that use this framework to guide their improvement efforts may not only raise their odds of higher scores on the specific Hold Harmless measures, but can also position themselves for better performance on the wide variety of other metrics that contribute to industry-leading performance (and its financial rewards).

1. Improving population health. Better population health is the North Star the entire health system is seeking. And the path to improved overall health and Star Ratings outcomes is through individual health achievements. By consistently improving health at the individual level, plans can improve it across entire communities over time. The journey starts with focusing on adherence to medications for chronic conditions, reducing fragmentation in care delivery, and launching initiatives to address the social determinants of health. Plans can use their results on prescription drug and HEDIS measures to target specific areas of improvement over the next performance year.

2. Lowering costs of care. Value for money is a shared top priority for CMS, consumers and health plans themselves, especially as risk-based contracting continues to become more prevalent. Plans will need to understand how to treat members in a proactive, holistic manner. Similarly, they will need insight into how the Star Ratings measures are linked to each other.

For example, taking action to improve performance on the Part D diabetes adherence measure can also raise scores on the Part C measure for controlling A1C rates, multiplying the impact of every dollar spent. By identifying “companion measures” that can be tackled at the same time, plans can reduce duplicative spending, avoid downstream costs from uncontrolled chronic conditions, and start to improve experiences for members.

3. Improving patient experiences. Member engagement with their plans and providers is tightly tied to quality. Plans will need to foster closer relationships with their members to remove barriers to access and empower ownership of their own care.

Plans can focus on honing their outreach strategies by proactively identifying gaps in care and/or socioeconomic barriers and addressing as many of these issues as possible during the fewest number of engagements. This reduces abrasion with members while building trust and maximizing internal plan resources.

4. Improving clinician experiences. Clinical workforces are stretched to their limit, making it more difficult for health plans to deliver on their promises to members. Clinical teams must be empowered with tools that remove unnecessary administrative burdens from the workflow while increasing access to valuable member claims data useful to inform clinician-member interactions.

Plans could consider deploying digital tools that surface “nudges” to their patient rosters to complete routine screenings, which can also reduce cognitive stress for providers while helping plans with their HEDIS measures. MA plans can also assist providers with allocating scarce resources appropriately by offering aid with risk scoring, outcomes-based prioritization, and other high-value analytics.

5. Advancing health equity. Traditionally underserved populations are a core component of many MA plans, rendering it crucial for plan sponsors to actively consider the unique needs of these groups. Plans must invest in better understanding of their members facing socioeconomic challenges. Utilizing analytics tools that can easily identify higher-risk individuals and workflow strategies, plans can connect these members with valuable community resources. Proactively resolving barriers to care can reduce spending, improve outcomes, and create better experiences while helping health plans achieve success on the HEI measure, and a wide variety of other Star Ratings measures.

Looking forward to a changed Star Ratings landscape in 2024

The next few years are going to bring many new changes to the Medicare Advantage environment. Plans that hope to hold onto their top rankings—or join their peers in the highest-performance brackets—will need to stay one step ahead of CMS’s efforts to enhance value and encourage quality across the MA market.

Plans will need to take a hard look at how specific changes like the updated QI Hold Harmless provision will impact their performance and outcomes. But they also need to keep the big picture in mind. Nothing happens in isolation when it comes to the Star Ratings, and thinking holistically about how to maximize value will only benefit plans during current and future evolutions of the rating system.

Using the Quintuple Aim as a guide for understanding the interconnectedness of the Star Ratings system is the best way to set plans up for success with upcoming adjustments while preparing for whatever is next on CMS’s list of priorities. Being proactive about costs, experiences, outcomes and equity will enable plans to take advantage of incentives, while serving their members in the best way possible.

Learn more about taking action on health equity to improve Star Ratings performance with the Quintuple Aim of Healthcare when you check out our recent white paper. AdhereHealth – Cracking the Code of the Quintuple Aim of Healthcare

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AdhereHealth Glenn WirickAuthored by:
Glenn Wirick
AdhereHealth Chief Commercial Officer