How to Improve Star Ratings with Health Equity Data

September 28, 2023


The Centers for Medicare & Medicaid Services’ (CMS) addition of the Health Equity Index (HEI) to the Star Ratings program challenges Medicare Advantage plans to address health disparities to maintain and improve scores.

We’ve previously outlined how the HEI will impact Star Ratings and how plans should prepare for the new regulations. Now, let’s dive deeper into data management strategies and tools for identifying social risk factors (SRF) and health disparities within Medicare Advantage populations to guide HEI improvements.

A Recap of HEI Calculations

The Health Equity Index will use minimum enrollment thresholds and performance on select quality measures for vulnerable populations to determine if plans will receive a boost to Star Ratings. For Measurement Years 2024 and 2025, these populations will include members who are considered low-income subsidy (LIS) or dually eligible (DE) for Medicaid and members who qualified for Medicare due to a disability. By comparing quality scores for members with SRF against national averages, CMS will determine HEI scores.

How Health Data Impacts HEI Scores

Accelerating performance within the HEI calculations requires an accurate understanding of where Medicare Advantage plans currently stand within the program. Determining quality scores for members with SRF is imperative for identifying and reducing health disparities at scale to impact HEI calculations. Without the support of the right SRF data and processes, any care gap closure initiatives will be limited to general populations.

To start addressing the immediate challenges of the Health Equity Index, plans need to prioritize assessing contracts for two data sets:

  • Health plan members that are LIS/DE and disabled
  • Performance on quality measures for members with SRF

Plans should also work towards developing whole-person views of members to support targeted and personalized care gap initiatives. Understanding how members want to be communicated with, what social determinants of health they experience, what challenges they face in receiving needed care and how likely they are to attend appointments will inform how health plans address Health Equity Index performance. The more member-level details captured, the more effective interventions will be.

How Can Plans Identify SRF?

The current SRF addressed in the Health Equity Index include LIS/DE and disabled members. Enrollment rates for members with SRF will determine if contracts are eligible for HEI rewards, and plans must know exactly which members will impact performance in the HEI.

For this initial set of SRFs, CMS will share contract-level enrollment rates with plans in their Monthly Membership Reports (MMR). However, plans need to keep a close eye on LIS enrollment rates. CMS defines LIS enrollment as any member who had LIS eligibility at any time during the year, and this data will need to be validated to capture members who have only been enrolled for at least a month. CMS also provides access to general Medicare Advantage and Part D contract and enrollment data, as well as annual reports for LIS enrollment.

While CMS is only focusing on a limited number of SRF to start, plans should prepare for the inclusion of other scenarios and social determinants of health. Future SRF can include:

  • Race and ethnicity
  • Limited English proficiency
  • Access to food, shelter and transportation
  • Sexual orientation and gender identity
  • Mental and behavioral health

How Can Plans Identify Quality Performance for SRF?

Unfortunately, health plans will not know which measures CMS will include in the HEI until after a measurement year has ended and all data is collected. National averages will also not be defined until all measure data has been analyzed. This limits plans’ abilities to strategically target high-value measures and optimize care gap initiatives for members with SRF to achieve performance benchmarks.

Plans will need to rely on historic data to guide health equity initiatives. Use both internal quality data and contract-level reporting for LIS/DE and disabled members through the Health Plan Management System (HPMS). Based on these reports, identify trends in health disparities among members with SRF and organize outreach to close care gaps. While this data may not reflect final scores, it can help move plans in the right direction.

The more robust data a plan collects for vulnerable members, the more capable they will be at advancing health equity. Public, internal and regulatory data should lay the foundation for quality improvement tactics and comprehensive survey tools can provide a deep understanding of member challenges. Pulse Surveys, mock-CAHPS® and Health Outcome Surveys and health risk assessments provide vital information about SRF that can help optimize health equity interventions.

What To Do with This Data

Identifying enrollment rates and health outcomes for members with SRF is only the first step in a winning HEI strategy. Once plans have captured this data, the next steps are to centralize, analyze and action it into personalized member engagement strategies to reduce health disparities. Plans should:

1. Centralize Member Records

Funneling member data into comprehensive records lays the foundation for ongoing engagement and improves overall plan efficiency. Start with enrollment data and the most up-to-date claims data available to understand where members are currently in their health journeys.

2. Identify and Bridge Data Gaps

Incomplete or out-of-date records will come up. Whether records lack current contact information, primary care providers or member sentiments, these data gaps should be identified early and addressed. Data validation software, member experience surveys and HRAs can help fill these gaps to support personalized and targeted interventions.

3. Assist Where Needed

Members will come to plans at different stages of their health journeys, and plans should be prepared with the right resources. The typical issues faced by a general population will often be more pronounced for members with SRF, and these vulnerable populations will have their own set of unique challenges. Plans can get ahead of these challenges by directly surveying members to determine where they need assistance and analyzing trends in SRF.

Moving All Members Forward 

Providing the best support to LIS/DE and disabled members to improve Health Equity Index performance will require new partnerships, strategies and technological capabilities. Whether you need assistance analyzing SRF data or engaging hard-to-reach members, Healthmine’s Expert Advisory Team and suite of digital tools can enable you to create data-driven health equity strategies that achieve results. Deliver equitable care to your most at-risk members when you leverage our expertise. Contact us for more information.

Healthmine is the leading member engagement and rewards solution focused on empowering people to take the right actions to improve their health.

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