My CMS Stars Strategy Isn’t Working, Now What?

Four Healthcare Solutions for Helping Medicare Advantage Plans Boost Centers for Medicare and Medicaid Services (CMS) Stars Ratings

The 2013 Centers for Medicare and Medicaid Services (CMS) Stars Ratings revealed to many Medicare Advantage plans that their Star rating improvement strategies are not boosting their Star scores to the extent they were expecting. The bar for what constitutes high-quality outcomes will continue to be raised, which is the intent of the program. Therefore, health plans must examine how to implement strategies to help improve their Stars ratings.

So, if your CMS Stars strategy isn’t working, now what? It’s time to modify your Star rating improvement strategy, with emphasis on speed to implementation before the next round of scores is released.

Accenture recommends a focus on four functional areas: Clinical, health plan operations, member experience and analytics. But before tackling these functional areas, plans must improve overall management of their CMS Stars rating program. Oversight of the program must be marked by dynamic management that is rapidly reprioritizing which actions to take to make best uses of people and dollars.

In October 2012, Medicare Advantage plans in the United States received their 2013 CMS Stars results. In the 2012 ratings, 29.7 percent of Medicare Advantage members belonged to plans that earned four Stars or above. In 2013, that percentage is 37.6.

All indications are that CMS will continue to evolve the 5-Star Quality Program as plans continue to improve their overall scores. The bar for what constitutes high-quality outcomes will continue to be raised, which is the intent of the program. If your health plan is underperforming vs. Star rating expectations, the time to modify your Star rating improvement strategy is right now, with emphasis on speed to implementation.

Read the full point of view piece to learn more about the four solutions to boost ratings.

Top-tier plans are doing well across four functional areas that influence the CMS Stars ratings: clinical, health plan operations, member experience and analytics. Organizations can work toward achieving a higher rating by following the healthcare solutions that align with those functional areas.

Before tackling these functional areas, health plans must focus on overall management of the CMS Stars rating program. Oversight of the program must be marked by dynamic management that is rapidly reprioritizing which actions to take to make best uses of people and dollars. Health plans must aggregate large amounts of disparate data to target and prioritize actions that have the greatest impact on measures. Health plans that are successful at this have the following characteristics:

• A fully dedicated Stars leader who is known as an operator that is data-driven and gets things done.

• Dedicated analytics resources and tools capable of turning data into actionable information.

• Management cadence that enables dynamic decision making about priorities, channels and magnitude of actions being taken to improve Star ratings.

• A governance model that includes active C-level steering.

Accenture recommends these four strategies for success:

1. CLINICAL STRATEGIES

   Pull all available levers. Successful improvement of the Healthcare Effectiveness Data and Information Set (HEDIS) and medication adherence metrics is dependent on two things: improving compliance with preventive care delivery and outcomes, and proving that it happened. There are multiple levers to be pulled that could improve care compliance.

   Prioritize. Of all the Star metrics, clinical measures tend to be the most dynamic over the course of the year. Plans with finite people and funds need the ability to prioritize the metrics, contracts and/or providers upon which they should focus.

2. HEALTH PLAN OPERATION STRATEGIES

   Industrialize the process. For operational metrics, take a “no excuses” approach to achieving five Stars. High-performing plans institute operational controls to drive:

   • Clear alignment of service models, performance goals and impact on Star ratings.

   • Clear processes and accountabilities around performance management.

   • Routine testing and validation of key processes, e.g., enrollment timeliness, TTY/TDD and foreign language interpreter availability and appeals timeliness.

   • Root cause analysis of what is fueling appeals and complaints(CTMs).

   • Defined process and responsibilities for fixing root causes of performance gaps.

3. MEMBER EXPERIENCE STRATEGIES

   One-third of Stars measures are based on member responses to two surveys: Consumer Assessment of Healthcare Providers and Systems (CAHPS) and the Health Outcomes Survey (HOS). Select plans have recognized the importance of member experience to influencing Star ratings (as well as retention) and taken action to apply their member engagement capabilities into this space.

4. ANALYTICS STRATEGIES

   Top plans are embracing analytics as an organizational differentiator. Specifically, they are:

   • Combining EMR, financial and administrative data to support strategic decision making.

   • Identifying and retaining top healthcare analytics talent.

   • Leveraging big data and using data-mining techniques.

   • Creating data management models to leverage every data source including claims, pharmacy, lab, marketing and survey results.

   • Moving beyond basic reporting to advanced analytics, predictive modeling, advanced forecasting techniques and optimization mathematics.

   • Emphasis on assembling the right data and quickly and accurately converting that data into actionable information.