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The Good in the CMS Medicare Advantage Star Ratings

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There are always high emotions with the official release of the Centers for Medicare & Medicaid Services (CMS) Star Ratings due to the nature of health plan ‘winners and losers’ but this October’s release of the 2023 Star Ratings brought more negativity and backlash than usual.

Several of the national and publicly traded Medicare Advantage (MA) plans are dealing with lawsuits and major shareholder losses but don’t let a few bad actors shine the light away from all the good the CMS Star Ratings program has done since its inception more than a decade ago. The Star Ratings program holds MA plans accountable to the year-over-year commitment of MA plans to do better by their members with access to affordable and high-quality care.

A Consumer-Focused Program

According to CMS, “The Star Ratings system helps Medicare consumers compare the quality of Medicare health and drug plans being offered so they are empowered to make the best health care decisions for them…with meaningful information about quality alongside information about benefits and costs to assist them in being informed and active health care consumers.”

MA plans take this to heart and develop corporate strategies and tactics to improve their Star Rating.

The goal of the Star Ratings program is to achieve the Triple Aim, a framework for improving patient experiences, the health of populations and reducing health costs. The Star Ratings program is not perfect. No quality measure or program is.

However, the Stars Program advanced the industry’s performance in vital quality measures, such as access to preventive care and prescription drugs, and increased member satisfaction; forced better and quicker coordination between providers and health plans; and transformed the culture, starting at the C-suite, to focus on the member.

Evolving Measurement Criteria to Meet Member Needs

Annually, CMS evolves the program to ensure plans are focused on the right measures, the right members, are not delivering the status quo, and are modernizing to meet industry demands. CMS uses Star Ratings to push plans to improve and to be held accountable for their performance.

For example, in 2017 CMS added the Categorical Adjustment Index (CAI) after research showed that low income and disabled members within the same contract did not receive the same care. CMS did not want to penalize plans or markets that have more low income and disabiled members and used the CAI to establish equity.

Another example is the increased weighting of CAHPS measures as a direct response to provider burnout. More emphasis on CAHPS scores drives the shift from providers spending time on low-value, process-based quality measures to more time managing patients’ health for optimal quality of life.

Furthermore, a primary reason CMS added the transition of care and follow up after emergency department visits measure to the 2024 Star Ratings calculations due to a glaring weak spot of health plans to care for members during vulnerable times. Transitions in care between settings bring several risks, including the potential for critical health information to get lost in the shuffle.

Finally, the proposed Health Equity Index is another example how CMS is challenging MA plans to take care of all their members and communities, regardless of zip code or demographics, to quickly eliminate disparities in care.

Revenue Equals Further Investments in Health Plans

Current reimbursement models still dictate plans focus on risk adjustment coding, and gap closure to drive revenue and quality bonus payments. Plans reinvest the revenue back into the health plan to be able to provider more comprehensive benefits, contract with higher quality providers, and invest in people and systems that improve health outcomes and deliver true patient-centric care.

After working in a dual provider owned and local MA plan and now consulting with many MA plans that are all unique, I am privileged to work side-by-side with many leaders that are mission driven and work every day to do better, and be better, for their members.

If you are a plan that lost a Star, do not lose hope. There is time left to impact the 2024 Star Ratings. Work the math path, find the highest impact members, and quickly survey the membership to identify any areas of CAHPS risk. If you need any assistance, reach out at Kimberly.Swanson@Healthmine.com.

Kimberly is a healthcare expert with more than 15 years of experience advising health plans through her robust knowledge of quality improvement solutions. Utilizing her strategic insights into HEDIS scores, NCQA measures, Star Ratings, Health Equity, population health management, and member satisfaction, Kimberly develops innovative strategies for connecting patients to care and improving plan performance for her clients. Kimberly has completed a Foundations of Health Equity Research certification through John Hopkins University.
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