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Making almost $5 billion in bonus payments, the Star Quality Rating System for Medicare Advantage plans operated by the Centers for Medicare & Medicaid (CMS) is the biggest and best-known of the many CMS value-based payment programs and pilots. Medicare Advantage plans receive a composite quality star rating on a scale from one to five, with five indicating the highest quality rating. The ratings are based on a variety of clinical, administrative and member satisfaction measures. Plans receiving four and five stars are eligible to receive additional quality bonus payments or rebates, which they must use to lower premiums and/or provide extra benefits to enrollees.

The Medicare star ratings program is designed to lower costs while delivering higher quality of care, and ultimately, improving population health. Many payers have room to improve their CMS star ratings. Higher star ratings can lead to more revenue, through CMS bonus payments and enrollment increases of up to 17% for a jump from three stars to four stars, with new members attracted to higher-rated plans. Our analysis of Medicare Advantage Prescription Drug Plan (MAPD) contracts that earned overall star ratings in 2018 and 2019 showed that success in just three of the seven measure categories determined which plans maintained or improved their ratings and which saw performance — and ratings — decline.

Taking the steps necessary to improve in these three key categories — medical records, medication and member satisfaction — will help payers gain the skills, programs and processes they’ll need to thrive as the industry’s shift to outcomes-based reimbursements accelerates.

Insight from analysis of 2019 star ratings

Our year-over-year analysis of 362 MAPD contracts showed that almost 25% of the contracts lost stars from 2018 to 2019. Among contracts with an overall 2018 star rating of four or higher, 31% lost stars in 2019.

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Achieving success in these three key measures requires a holistic and continuous approach to quality improvement that incorporates digital tools, a silo-free data landscape and close collaboration with providers.

Plans with four stars and above outperformed the other contracts across measures that are affected by providers and members as well as a payer’s internal systems and processes. The “Provider-focused medical record” metric involves clinical data acquisition by payers from medical records held by providers. The “Medication” metric is based on provider medication management. The “Member-focused satisfaction” measure is based on members’ perceptions of a plan as reflected in a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

In our experience, plans that perform well in these three categories have cross-functional collaboration, few data silos and strong data governance. Clinical, pharmacy, member experience, appeals and grievance, care coordination and encounter data analytics all are incorporated into quality efforts.

Sustaining success, and four-star ratings, also requires a commitment to process improvement across the value chain. To wit: a high score for the medical-record metric indicates a plan can efficiently retrieve medical records from provider offices. This requires medical record chase analytics for higher yields and good provider relationships and contacts.

Digitally driven tools and strategies can help payers achieve these capabilities. Here are five key steps that payers can take to improve performance under the Medicare star ratings program.

1    Incorporate artificial intelligence (AI) and natural language approaches to enhance a 360-degree view of members.

Machine learning and natural language processing (NLP) can help streamline investigations into electronic health record (EHR) progress notes and discharge summaries, which are important sources of social determinants of health (SDoH) data. SDoH information is becoming a key driver in closing gaps in and improving quality of care. In our experience, machine learning and NLP tools can cost-effectively and efficiently extract this data.

2    Integrate HEDIS and star analytics with contact center operations and CRM systems.

Empower member service representatives by incorporating care gap insights and comprehensive member views from HEDIS® and star systems with customer relationship management (CRM) systems such as Salesforce. The goal is to provide a holistic view of the member. That enables plans to provide members with information about recommended screenings, interventions and medication refills in fewer contacts by using a member’s preferred channels. This will help improve member satisfaction while also closing care gaps to improve HEDIS and star ratings.

3    Create a multidisciplinary data science team.

Pair subject matter experts with data analytics tools. Create a team with members who are experts in statistics, HEDIS analytics, clinician analytics, R and SQL. Include associates with strong client relationship experience to ensure the project remains focused on achieving practical results.

4    Share provider quality-incentive programs and collaborative scorecards.

Provider contracts that incent better performance in HEDIS measures, better coding (use of CPT Category II codes) and sharing of data and medical records will lead to higher star ratings.

Payers could choose to emulate value-based traditional Medicare programs like the Merit-based Incentive Payment System and Advanced Alternative Payment Models with their provider groups. Star rating measures also are good starting points. In addition, we have seen payers proactively address newly introduced HEDIS measures such as “transitions in care” that require providers to render and document care within a narrow timeframe.

These programs would require a provider scorecard that enables payers to collaborate with providers by sharing gaps in care intelligence. Scores would also tap into the often-competitive nature of providers by showing them their performance vis-a-vis peers. This scorecard could be a widget in an existing provider portal or embedded in the existing EHR workflows as new CMS rules improve system interoperability.

5    Leverage supplemental data acquisition and interoperability standards.

As CMS interoperability rules go into effect, payers should consider implementing a year-round supplemental data acquisition strategy. Supplemental data from provider files is increasingly critical and aligned with electronic clinical data systems and the future of quality reporting. Interoperability standards like HL7 FHIR will enable payers to retrieve data from EHRs in real time. That should lead to faster identification and closure of care gaps. It also should improve ratings and reduce the medical-record retrieval burden during the HEDIS hybrid season.

Best practices: How a boutique Medicare Advantage plan improved from 3.5 to 4.5 stars in a year

A southeastern Medicare Advantage plan utilizes a narrow network of quality providers engaged via risk-based arrangements to deliver concierge-level services to plan members. To grow its business and successfully compete with larger health plans, the payer needed to raise its CMS star rating from 3.5 to 4.0 or higher and improve its HEDIS measures. To achieve these objectives, the payer needed to:

  • Enhance clinical data acquisition and management functions to help identify, analyze and close care gaps more efficiently.
  • Align physician groups with its CMS star improvement goals.

Focusing on key preventive and chronic care management measures, we conducted a four-month program to increase the plan’s CMS star rating for improvement measures.

We addressed the payer’s unique closed-loop care-gap registry and point-of-care quality needs by building a new care-gap registry module for the plan. Using our quality-as-a-service analytics tool, we provided insights unavailable in claims data. With these, the care-gap registry module delivers actionable clinical intelligence and pay-for-quality metrics to the plan’s providers. The providers use the module to submit evidence of closed care gaps from medical chart and electronic health record data.

The application allows the payer to work prospectively throughout the year to create HEDIS-like performance measures and use that data to collaborate with providers to identify and close care gaps. That dramatically reduces the number of year-end medical reviews required.

With a staff of two, and in less than 120 days, the plan optimized its HEDIS performance on preventive and chronic care management measures, exceeding its target 4-star rating and achieving a 4.5 overall star rating for 2019. That improvement equates to more than $16 million in additional revenue to the plan. That enabled it to provide bonuses to physicians for closing gaps in care. In addition, the plan used the data to offer an innovative and highly successful incentives program that rewards members who receive recommended preventive care.


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