The release of the 2019 Call Letter, which allows plans to include quality improvement and member intervention costs in their bid, signals the Centers for Medicare and Medicaid Services’ (CMS’) ongoing and growing commitment to quality improvement and long-term health initiatives. In the past, plans have tried varying strategies to improve quality and star ratings with varying levels of success. However, it is apparent that CMS expects plans to have a robust program for detecting gaps in care that notifies and incentivizes members to act, in addition to ensuring data accuracy and staying abreast of guidance changes.
In 2007, CMS introduced the Star Ratings system for Medicare Advantage plans. Medicare Advantage plans are rated one to five stars, based on defined quality measures for both Part C and Part D performance. The initial intent of the Star Rating system was to create a tool for consumers to use in selecting a plan.
Star Ratings have moved beyond the consumer selection process and are now a critical part of plans bonus payments and marketing abilities. Medicare Advantage plans achieving a 4 star or greater rating receive a 5 percent Quality Bonus Payment (QBP), which is calculated on a per member per month (PMPM) basis. Five-star plans are not limited to the annual enrollment period (AEP), but are able to market and enroll members year-round. Beneficiaries can join these plans at any time via a special enrollment period (SEP). Plans receiving less than a 3 Star overall rating are considered poor performing and, if repeated three years in a row, could possibly lead to contract termination. Because of this, it is essential that Medicare Advantage plans have a strategy for improving and maintaining Star Ratings.
1. Data Integration Drives Interventions Related to Clinical Quality of Care Improvement Measures
Star Ratings are calculated through the compilation of a variety of sources, including data reported from health and drug plans, data collected by CMS contractors, CMS administrative data, and survey of enrollees. Of these, one particularly critical data source is data from the Health Care Effectiveness Data and Information Set (HEDIS), which is a set of standardized clinical performance measures based on staying healthy screenings, tests and vaccines, and managing chronic long‐term conditions.
Annually, HEDIS measures on average make up approximately 38 percent of a Medicare Advantage plan’s overall rating. The HEDIS measures are followed closely by enrollee Consumer Assessment of Healthcare Providers and Systems (CAHPS), and Health Outcome Surveys (HOS), all of which are a priority for a health plan looking to achieve a 4- or 5-star overall rating. In partnership with their provider network, plans should be actively identifying gaps in care and establishing clinical outreach programs to close identified gaps.
Many plans struggle with integrating the disparate data to reconcile gaps in care. Even when this data is integrated, the process to target and identify members and getting those members to take actions that will drive results are beyond many plans’ current staffing and technology recourses. The most successful star rating strategies will automate data inputs from a variety of sources, review real-time and actionable data, and reward and incentivize member engagement and changes in health behaviors.
2. Reconciling Star Ratings Plan Preview is Essential
A comprehensive Star Rating program should also carefully review CMS’ plan preview data, as well as ongoing data. During the CMS annual plan review period, with the first phase occurring in August of each year, a plan is required to conduct a review of the data provided by CMS, validate internally and raise directly to CMS any discrepant data. A second plan preview follows in September and will include any revisions from the first plan preview.
Plans should not assume that just because the data comes from CMS, it is accurate. A variety of factors can affect the data accuracy, and CMS expects Part C and D sponsors to have a methodology and process to closely monitor, review and reconcile data for each measure on an ongoing basis. Throughout the year and prior to the agency’s official plan preview, a plan should immediately alert CMS of any suspected data issues or errors that have been identified to allow sufficient time to investigate and process any necessary data corrections.
In addition to validating the accuracy of data, plans should be analyzing the plan preview and on-going data to further refine their star strategy, based upon what the data reveals.
CMS Annual Star Rating Cycle
- November 2017-February 2018: CMS provides notice of the anticipated methodology changes for the annual measurement and display ratings (2019 Ratings).
- February-April 2018: CMS announces the final methodology for the 2019 Star Ratings in the 2019 Call Letter.
- Summer 2018: CMS provides updates to the upcoming Star Ratings release and training and conducts two plan preview periods to identify any necessary data correction.
- October 2018: CMS publishes the 2019 Star Ratings for the Annual Enrollment Period (AEP).
- November 2018: Sponsors who believe their measures were incorrectly reported/rated by CMS may appeal. This process may only be initiated based on a calculation error (miscalculation) or a data inaccuracy (incorrect data).
3. Guidance Changes Impact Future Star Strategies
Even with all the controls above in place, plans’ Star Rating programs can miss the mark by failing to stay abreast of changes in guidance and changes in measures. Annually, CMS releases the final Call Letter, which includes CMS’ changes made since last year’s Star Rating, including the addition of new process measures, the return of a process measure, the removal of an intermediate outcome measure, and several small measure specification updates. Reviewing the draft and final issuance of the Call Letter are critical steps in revising and re-prioritizing a plans’ Star Rating strategy.
As an example, in the 2019 Call Letter, CMS added Statin Use in Persons with Diabetes and Statin Therapy for Patients with Cardiovascular Disease. These are new measures plans will want to track, collect data and ensure medication compliance.
BluePeak Can Help
BluePeak’s Star Rating Program includes a powerful, automated, real-time and customized identification and intervention process focused on HEDIS and other clinical measures, which result in better quality scores and higher Star Ratings for Medicare Advantage Plan Sponsors. Plans experience, on average, an improvement of one star per measure targeted. BluePeak also provides consulting services, based on regulatory expertise, guidance on best practices to close identified gaps in care, and interpretation of existing and new Star Ratings guidance and its impacts, as well as on-going assessments of a Plan’s Star processes and infrastructure.
