The Centers for Medicare and Medicaid Services (CMS) developed a performance rating system for Medicare Advantage (MA) and Prescription Drug Program (PDP) plans as a report card of how plans managed key requirements. The system ranges from one star (“poor”) to five stars (“excellent”) and each year in the fall, the ratings for the prior year are announced. Low performing plans (considered those with less than three stars) are considered “at risk” and are in danger of contract termination.
MA health plans are evaluated on five key metrics:
- Staying healthy: screenings, tests, and vaccines
- Managing chronic (long-term) conditions
- Plan responsiveness and care
- Member complaints, problems getting services, and improvement in plan performance
- Health plan customer service
Additionally, health plans offering prescription coverage and stand-alone PDPs are evaluated on:
- Drug plan customer service
- Member complaints, problems getting services, and improvements in plan’s performance
- Member experience with the plan
- Drug pricing and patient safety
In 2014, MA-PD plans averaged 3.05 stars and PDPs 3.84 stars with the vast majority of plans over the three star “at-risk” benchmark. In theory, the ratings assist consumers in measuring one plan against others to consider the best performing plans. While CMS intends for star ratings to be a major factor in plan choice among seniors, a recent focus group study by Kaiser Family Foundation disputes this idea. In general, Kaiser found most seniors were unfamiliar with the ratings and did not use the Medicare Plan Finder comparison tool. Those that did know of the ratings stated they, “…did not play a major role in their decision-making process.” Additionally, if satisfied, seniors were generally not likely to change plans.
Though star ratings improvements are not likely to result in significant membership increases, they continue to be an important part of CMS benchmarking. Star ratings are incorporated into past performance reviews for new application requests and/or service area expansions. Further, in 2015, CMS will begin to exercise its authority to terminate contracts that are low performing. As such, here are five ways to improve star ratings:
1. Collaborate with all leadership levels within your organization – top down. Success depends on executive-level commitments and collaboration among various departments within an organization. The organization’s leadership needs to be made aware of the financial impacts of star ratings to the health plan. Quantify the costs and benefits to build support and justify a budget.
Team collaboration is key to achieving many of the improvements and can better develop actionable data and create creative solutions. Think about how departments can more successfully coordinate their activities to improve ratings. Successful quality initiatives require funding, support, and resources from throughout the organization.
2. Combine initiatives to affect multiple measures. Examine data sources and measures where one program or improvement can positively affect multiple ratings. This promotes consistency, overall quality, and smart use of resources. Think about Part C measures using HEDIS and HOS data, incorporating case management into the overall strategy, and examining utilization data more closely. Consider integrating medical and pharmacy efforts.
3. Use outside vendor resources and reporting tools wisely. If you outsource functions such as Medication Therapy Management (MTM) and pharmacy claims processing, these vendors should collaborate to improve star ratings and display measures. From reporting to quality improvement initiatives, vendor expertise helps to supplement internal resources and directly affects many of the Part D measures. If there are additional fees, ask for Return on Investment (ROI) guarantees for the dollars spent and help in quantifying the projected costs and benefits.
4. Seek out the “low lying fruit.” Improvements that take fewer resources or may be quickly implemented provide positive outcomes and quick ROI. Consider predictive modeling tools to identify and better target interventions and actions for the most effect. Small successes build positive momentum toward the larger and longer term changes needed.
5. Look for measures with the highest weights or improvements that may positively affect multiple measures. Some measures in Part D, such as adherence, are weighted three times higher than other measures. Ratings measures such as D12, D13, and D14 for medication adherence and D10 (high risk medications) and D11 (diabetes treatments) are weighted at 3x the norm and measures such as C31 (health plan quality improvement) and D06 (drug plan quality improvement) are now weighted at five versus the prior three.
In fact, all but one of the Part D star ratings measures carry a weight greater than one (1). Thus, focusing resources and efforts on the highest rated measures provides the strongest positive impact to the overall ratings and thus the perception by consumers and CMS. A focus on high risk medications, adherence measures, and diabetes treatments (D10 – D14) could yield the strongest overall improvements.
If you are unsure how to get started, contact your Excelsior Solutions Consultant. We can provide strategies, tools, and ideas for long-term star ratings improvements.