Whether you are a health plan leader or financial executive, you’re well aware that achieving and maintaining excellent Medicare Advantage Star Ratings has become increasingly difficult. At best, a high rating is a moving target as CMS continually evolves the program and consumers refine their expectations. For example, CMS recently placed greater emphasis on measurement categories that have often eluded health plans: improving medication adherence and member experience.
Do you have the right tools to hit critical Medicare Advantage (MA) Star Ratings cut points required to earn quality bonus payments, even as competition becomes more fierce? Here we describe how health plans can build or improve upon a strategy to achieve the highest MA Star Ratings.
Where Do Star Ratings Measures Come From?
Medicare Advantage Star Ratings are based on a number of quality and performance measures, many of which are developed and maintained by third parties.
Healthcare Effectiveness Data and Information Set (HEDIS®)
HEDIS® is a suite of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS measures assess a plan’s clinical effectiveness, its accessibility of care, how members experience care, a member’s use of resources and the quality of information provided to members by the plan.
Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
CAHPS® is a portfolio of survey instruments maintained by the Agency for Healthcare Research and Quality (AHRQ) to assess a patient’s experience of care in a range of settings. The surveys were developed in collaboration with multiple agencies within the U.S. Department of Health and Human Services, including CMS, which draws on specific elements of CAHPS® surveys as part of the Medicare Advantage Star Ratings.
Medicare Health Outcomes Survey (HOS)
The Medicare HOS gathers patient-reported health status data from Medicare beneficiaries. Developed and maintained by CMS under the guidance of a technical expert panel, HOS data are the basis of two Part C measures: “Improving or Maintaining Mental Health” and “Improving or Maintaining Physical Health.” HOS data also contribute to several HEDIS measures.
Pharmacy Quality Alliance (PQA)
PQA is an important contributor to Part D quality reporting measures. Five PQA measures are part of the 2021 Star Ratings: three focused on medication adherence, one on medication therapy management, and one on use of statins in people with diabetes. PQA measures are among the most impactful Part C measures in terms of both patient outcomes and the MA Star Ratings revenue opportunity for health plans. PQA measures also support targeted quality improvement at health plans through display measures. For 2021, eight PQA measures are on display and ten other PQA measures are reported to health plans in patient safety reports.
In addition to serving as the steward of most MA Star Ratings measures, CMS develops many of those measures. It uses several automated systems and vendors to collect data for measures examining issues such as call center performance, complaints and disenrollments. Some examples include the Complaints Tracking Module and the Medicare Beneficiary Database Suite of Systems.
The MA Star Ratings data collection effort by health plans and providers and the subsequent calculation effort by CMS are major undertakings. As a result, MA Star Ratings are a reflection of care provided two years prior to their release each October, in conjunction with the start of the annual open enrollment period. For example, data collected and reported to CMS in 2019 for care delivered in 2018 informed the 2020 MA Star Ratings.
Groundwork for Success
Assemble the Right Team.
It’s no coincidence that MA plans that consistently earn high MA Star Ratings point to an effort by a year-round multifunctional, strategy-driven team as the secret to their success.
Your team should create or build upon a common business strategy that includes goals, objectives, evaluation and management of resources and communications. Consider representatives from each of these departments in order to assemble a robust team: health services; quality; case management; utilization management; pharmacy; medical; nursing; network operations; customer service; member communications; provider communications; marketing; sales; product; risk; and compliance.
Are you surprised by the extent of the suggested departments? If so, look back on the range of data sources that comprise MA Star Ratings to understand the need for such representation. A successful health plan fuels a train that is led by its product development team. Marketing serves as the body of the train and crafts the perfect message for its sales team to generate qualified leads who, in turn, will become health plan members. The first impression and onboarding experience matters just as much to your members as the day-to-day when it comes to their overall experience with the health plan.
Create an Action Plan.
Established health plans have identified best practices and engagement tactics that should be considered in a comprehensive MA Star Ratings strategy. Before giving up on what you’ve already tried or talked about, revisit tactics that are ready to launch and talk through what you haven’t tried and what needs an overhaul. It is also important to recognize what you should leverage, especially in terms of seasonal topics and national awareness months that coincide with individual measures. This exercise should reveal the gaps you must address and prioritize based on the likelihood to improve outcomes of each MA Star Rating measure.
Understand Your Primary Stakeholders.
CMS developed the MA Star Ratings system to give Medicare beneficiaries an objective measure of a plan’s performance on metrics other than cost. The rating system gives consumers a way to also consider quality as they make their enrollment decisions. A five-star overall rating indicates that an MAPD plan delivers quality care and has excellent beneficiary satisfaction. This can only be achieved with a strategy that optimizes collaboration with members and a network of providers.
Communicating with members is one thing, but truly understanding which members should receive information A and which should receive information B can be lost on some health plans. Often, communication preferences, social determinants of health (SDOH) and case management interests take a back seat to risk models. Yet with an increased weight on consumer experience measures, these factors are vital to improving your CAHPS® outcome — entirely from a member’s perspective — in addition to improving medication adherence, HEDIS®, HOS, member retention and other quality metrics.
Let’s look at Part D measures as an example. Although some are titled “medication adherence,” these measures truly examine effective treatment of chronic health conditions. Do your members physically have in their possession the medications needed to treat their chronic conditions? Do they fully understand what they are taking, when they should take it, and why they need it? With prescription drug event (PDE) data impacting a plan’s overall rating, it is imperative for a health plan to focus on improving adherence outreach and removing obstacles members may face in improving medication adherence and overall health outcomes.
Adherence outreach to members who struggle most with this issue is a key factor in closing gaps in care. For all members, understanding the benefits, health services, digital tools and other programs available to them will help improve clinical outcomes, well-being and member experience with the health plan.
HEDIS® is a high-priority data source when calculating MA Star Ratings. It determines how well a health plan manages both preventive care and chronic diseases or conditions, measures that rely on clinical care outside of the health plan’s control. This is one of the reasons that meaningful communication and engagement with providers and their office staff throughout the year can make a difference at the end of the year when health plans push to close gaps.
You may also consider financial incentives for accurate use of claim codes and for significant improvements. Engaging providers in MA Star Ratings education will encourage them to make progress in value-based care, improving clinical outcomes and reducing costs.
Incorporate an Editorial Calendar.
An editorial calendar should highlight a cadence of stakeholder communication and adherence outreach topics that work in coordination with the day-to-day operations of the health plan. A robust calendar addresses individual measures that help to achieve the big picture, including all applicable PQA, HEDIS®, CAHPS® and HOS measures, with decided tactics and responsible departments.
Be careful here. Abrasion is worse than a lack of communication, so make a point to prioritize engagement optimization. Some weeks or seasons may see more action than others, but each day is important to your plan’s success.
Because measures and calculations are likely to change from year to year, keep your strategy fluid. This will help to identify shifting priorities as well as which improvement tactics have proven the most successful and which need additional effort.
Identify Common Roadblocks.
The roadblocks you identify as you build your strategy may come in the form of data, performance, accessibility, or action. You’re not alone if you immediately identify data as your company’s biggest roadblock to higher MA Star Ratings. It’s time to invest in a digital tool that can make data simple for health plans.
How Resolve™ Can Set Your Strategy Ahead of the Rest
You can survive and thrive with a strategy that includes the Adhere™ platform’s Resolve™ solution for health plans, and turn your real-time data into actionable insights that lead to improved outcomes and cost savings. Resolve™, part of the Adhere™ platform, is the ideal digital tool to overcome many of your identified roadblocks. It is the only consumer-centric solution that enables you to optimize scores by addressing 80.5 percent of Medicare Advantage Star Ratings weight related to medication adherence, quality improvement and consumer experience.
The platform, offered as a software-as-a-service (SaaS) or a tech-enabled clinical outreach solution, targets gaps from dozens of sources. Predictive analytics are integrated into an intelligent clinical workflow customer relationship management (CRM) tool to maximize each interaction with the consumer or their provider.