Medicare Advantage Star Ratings Enhancement: The Cost of Complacency for Health Plans

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Medicare Advantage (MA) Star Ratings are the most critical evaluation of MA Prescription Drug plans, standing as a designation of the quality of a plan’s healthcare and drug services. Born out of the Affordable Care Act (ACA), these ratings give consumers a way to compare Medicare Advantage plans based on performance and to consider quality as well as cost when making enrollment decisions. In the 2019 Contract Year, 77% of Medicare beneficiaries enrolled in Medicare Advantage were in plans with four stars or better.

But MA Star Ratings are much more than a way for Medicare Advantage plans to attract and retain new members. They can also increase financial incentives to the tune of about $450 per member per year. MA plans that score above the four-star benchmark are eligible to receive a value-based reimbursement from the nearly $11.6 billion annual Quality Bonus Payments (QBP) pool allocated by the Centers for Medicare and Medicaid Services (CMS). This creates somewhat of a sink-or-swim scenario for Medicare Advantage plans. It’s Darwinism for healthcare where only the strongest quality plans can compete — Medicare Advantage plans that receive a QBP are required to improve member benefits, thereby building a better product to compete for consumers in future years.

Challenges of Continuous Improvement

Improving MA Star Ratings scores can be difficult, even for plans that perform well in a given year. Each year, CMS develops cut points based on the performance of all plans for each measure over the previous year. As health plans improve their quality, the distribution scores shift. In other words, the threshold keeps rising — making it harder for MA plans to move the needle from four to five stars. According to the latest federal data, approximately 49% of the 400 MA plans with prescription drug coverage that received a rating earned four stars or higher for 2021. About 52% of MA plans scored four stars or more for 2020.

Now, the Medicare Advantage Star Ratings bar is rising yet again, which means even fewer MA plans may be able to tout a four- or five-star rating in the years to come. CMS hasn’t added any new measures for Contract Year 2021, but it did materially change the methodology for calculating quality scores. As a result, Consumer Assessment of Healthcare Providers & Systems (CAHPS) consumer experience surveys have emerged as the key area of focus.


The CAHPS Imperative

Customer experience measures have been a component of Medicare Advantage Star Ratings for years, but CMS recently made dramatic changes to the weighting of measures related to CAHPS. Specifically, CAHPS measures will be quadruple-weighted beginning with Contract Year 2021, equating to 32% of the overall Medicare Advantage Star Ratings score. Medication-related measures make up a total of 52% of overall MA Star Ratings, making medication adherence and consumer experience the two top priorities for MA plans to succeed in CMS Star Ratings.

MA plans cannot afford to be complacent when it comes to the consumer experience and medication adherence. With $11.6 billion in the annual value-based care pool on the line, the cost of maintaining the status quo is simply too high. Developing a strategy and leveraging technology will be crucial to ensure strong CAHPS performance as well as medication-related measures, particularly for dual-eligible special needs plans (D-SNPs). Analysis by AdhereHealth shows that the changing weights put D-SNPs at the highest risk because, unlike other quality and adherence measure adjustments, CMS does not provide D-SNPs a curve for CAHPS. In Contract Year 2018, when the weighting for CAHPS was 1.5x, D-SNPs performed 5.8% worse for CAHPS as compared to non-D-SNP plans. The gap is expected to widen further now that CAHPS measures are quadruple-weighted.

The COVID-19 pandemic creates even more urgency for MA plans to transform their approach to improving the consumer experience. A recent report by experts at McKinsey found that more than three-quarters of Americans are distressed by the pandemic. CAHPS surveys cover key measures such as “getting needed care” and “how well doctors communicate.” But in the midst of the crisis, some MA plan members remain reluctant to go to the doctor at all. The coronavirus crisis also brings to the forefront many of the social determinants of health (SDOH)-related issues patients often face when obtaining care or medications. Barriers for many consumers include lack of access to transportation and food instability, among many other factors. At-risk populations need to know what resources are available to get support so they remain adherent and healthy.

How To Be a Rising Star Amid Uncertainty

As a matter of critical importance, MA plans must address CAHPS measures as part of routine consumer engagement. The consumer experience approach needs to become a year-round focus integrated into other quality improvement activities for Medicare Advantage Star Ratings — most notably, those focused on medication-related measures. Here are three strategies to ensure success.

1. Be Proactive: Use Data-Driven Insights To Drive Communication

MA plans must proactively investigate what keeps their consumers from accessing needed care, filling prescriptions or adhering to treatment plans. A consumer’s ability to easily access needed care or follow treatment plans may be rooted in nonmedical barriers, such as lack of transportation or trouble making copayments. If a consumer has transportation to and from a medical visit but not to the pharmacy, a vital prescription may go unfilled. COVID-19 has only exacerbated consumers’ nonmedical challenges, creating greater need for plans to work with high-risk members.

To get beyond CAHPS surveys and reveal the real drivers of plan performance, you must leverage (or, if necessary, build) predictive analytics, integrate data across the plan and with providers, and design intelligent clinical workflows. As explained in the analysis by AdhereHealth recently published in the American Journal of Managed Care, “modern tools leverage near-real-time health plan data (e.g., medical claims, pharmacy claims, hospital discharge, HEDIS and consumer surveys) to produce near-real-time target and stratification of at-risk measures to guide clinicians in their engagement with consumers and their doctors. These tools should be robust in features, enabling real-time clinical focus to address SDOH, leverage health plan benefits, available community resources, and pharmacy enrollment to maximize the engagement. Tackling SDOH actions in a discrete method, not free text notes, will enable additional analytics and reporting.”

2. Ditch the Spreadsheets and Modernize Operations

Despite the incredible incentive of the multi-billion-dollar QBP pool, MA plans almost exclusively use antiquated case management tools, such as spreadsheets or Access databases, and transactional measure campaigns to close gaps in care for Medicare Advantage Star Ratings. This practice is inefficient and disconnected, and it eliminates the ability to fully aggregate invaluable data from multiple sources. Further, it prevents the clinical outreach team from maximizing each interaction to drive the next step in the consumer’s adherence journey.

Plans should invest in a customer relationship management (CRM) tool that optimizes each interaction and builds an ongoing positive consumer experience. Every department directly or indirectly affects members’ experiences. Every department, therefore, needs to be part of the consumer experience improvement strategy. Journey mapping or communication audits can help leaders understand and improve the range of consumer touchpoints. CRM tools can help increase the efficiency and effectiveness of every communication.

3. Get Unstuck: Overcome the Power of Inertia

Consumer experiences and medication adherence will not improve on their own. Put your health plan in the best possible position for Contract Year 2021 and beyond by taking strategic action now. CAHPS surveys are typically collected in the spring, so plans need to move aggressively and take immediate action to perform well under the new Medicare Advantage Star Ratings formula in the 2021 measurement year.

Consider Newton’s First Law, which states that an object in motion stays in motion. This means the most critical action is simply taking that first step. Get the right people involved up front: Bring in experts who know your business and have proven success using technology to maximize Medicare Advantage Star Ratings performance. Plans that do nothing to improve their consumer experience will likely see decreased ratings, attrition and a negative impact on value-based reimbursements. This is the literal cost of complacency, and it is why CAHPS and medication adherence should be the front-and-center focus of Medicare Advantage Star Ratings improvement efforts.

An Analytics-Driven Approach To Enhancing Medicare Advantage Star Ratings

For MA plans in search of a proven solution to support the elevation of Medicare Advantage Star Ratings, consider Resolve™ for Medicare Advantage Star Ratings, an Adhere Platform™ solution. Resolve is an intuitive, consumer-centric software-as-a-service (SaaS) offering that puts your data to work. It addresses 80.5% of Medicare Advantage Star Ratings with an emphasis on improving medication adherence and consumer experience.

Resolve analyzes near-real-time data from dozens of sources (e.g., medical and pharmacy claims, eligibility, HEDIS, hospital discharge, direct consumer and provider inputs) to produce a streamlined, intelligent CRM clinical workflow. Resolve analytics prioritize at-risk consumers and automatically integrate actionable insights into targeted clinical workflows for outreach, ensuring clinicians can connect consumers with the information and resources they need to overcome their individual barriers to medication adherence and care. The platform is scalable to optimize your team’s performance and ensure that the right consumers receive the right communication at the right time.

Harness the Power of Data to Improve Medicare Advantage Star Ratings

Complacency won’t serve you or your consumers well. It’s time to adapt by harnessing the power of data with Resolve.