What payer doesn’t want to achieve a higher star rating to receive CMS bonus payments and attract new members?

In addition, to the lure of bonuses is the very real fear of penalties—which can be quite a motivator. The Centers for Medicare & Medicaid Services (CMS) is committed to achieving the 13 percent to 14 percent nationwide cuts outlined in the Affordable Care Act, which will hit plans fully by 2017, according to an article by PwC’s Strategy&. “In an industry where many plans operate with margins in the low single digits, any reduction is a daunting figure,” the authors of the article write.The best way to offset penalties is to get high star ratings, which can reduce the cuts from 14 percent to nine percent if a health plan achieves at least a four-star overall rating, the article says. “Improving performance to capture these bonuses won’t be easy, but the rewards will be significant.”


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Payers have steadily increased their star ratings over the past few years, CMS has found. This should be encouraging to payers, because it shows it is possible to improve ratings. According to CMS, between 2013 and 2016, the average overall star ratings weighted by enrollment for Medicare Advantage – prescription drug coverage (MA-PDs) showed that:

  • Approximately 49 percent of MA-PDs (179 contracts) that will be active in 2016 earned four stars or higher for their 2016 overall rating.
  • This is nearly a nine-percentage-point increase from 40 percent of active contracts earning four stars or higher for their 2015 overall rating.
  • Weighted by enrollment, close to 71 percent of MA-PD enrollees are in contracts with four or more stars.
  • This is nearly an 11-percentage-point increase from 60 percent of enrollees in contracts with four or more stars in 2015.

How to Get Higher Star Ratings

For the plan year that starts January 1, 2017, CMS has defined nearly 50 Medicare Part C and Part D quality measures, according to CVS Health’s Insights, in an article titled “Strategies to Help Boost Medicare Star Ratings.”

“Plan performance will be reflected in the 2019 star ratings the agency is expected to publish in October 2018. So now is the time to implement improvement policies and procedures to positively influence ratings,” CVS Insights says.

CVS Health advises to establish “a holistic and accountable approach” to better ratings. Here are seven tips from CVS Health on ways to improve star ratings:

1. Launch a targeted member outreach. Use predictive analytics to find those beneficiaries who need additional support. Try to find the point during treatment or therapy that will most effectively get the patient engaged, and offer support then.

2. Hold monthly meetings with executive leaders. At the meetings, review star ratings and focus on a couple of key areas within the measures that could be improved. Then brainstorm on ways to achieve better performance.

3. Review star ratings monthly. Have the executive sponsor of each measure encourage collaboration on improving ratings at these meetings. This also provides a regular forum for teams and leaders to identify other challenges and ways to overcome them.

4. Enhance the beneficiary experience. “Understanding the beneficiary experience can help identify opportunities for improvement that translate into high Consumer Assessment of Healthcare Providers and Systems (CAHPS) and call center monitoring scores,” CVS says. Also, use grievance and complaint tracking, as well as ad hoc survey results, to determine additional steps for improvement.

5. Engage providers. Don’t forget to incorporate the health plan’s plans for improved star ratings into the physician’s workflow. It doesn’t hurt to provide financial incentives to providers who are making progress toward value-based care—which is to improve outcomes while reducing costs.

6. Get pharmacists involved. Pharmacists can be a big help in improving several of the clinical and operational star-ratings measures, including complaints about the drug plan, voluntary disenrollment, and CAHPS results related to obtaining prescriptions. “Pharmacists can also help with adherence and medication therapy management, and [can] council members about gaps in care and use of cost-effective generics,” CVS says. Health plans should work with their pharmacy benefits manager to set up interventions that pharmacists can take. It’s also a good idea to offer financial incentives to pharmacists, just like physicians.  

7. Empower customer care representatives. They can be critical in helping resolve a beneficiary’s concerns when he or she first calls in. Give empathy and engagement training to customer care representatives to help boost beneficiary satisfaction.

CenseoHealth says it’s never too late to improve ratings. In its article “The Final Push: Simple Q4 2016 Star Rating Tactics,” CenseoHealth says, “There is still time to make a difference, but a push for five stars takes multiple approaches.”

What tactics have worked best for you to improve star ratings?

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About The Author

Reveleer is a healthcare-focused, technology-driven workflow, data, and analytics company that uses natural language processing (NLP) and artificial intelligence (AI) to empower health plans and risk-bearing providers with control over their Quality Improvement, Risk Adjustment, and Member Management programs. With one transformative solution, the Reveleer platform allows plans to independently execute and manage every aspect of enrollment, provider outreach, data retrieval, coding, abstraction, reporting, and submissions. Leveraging proprietary technology, robust data sets, and subject matter expertise, Reveleer provides complete record retrieval and review services, so health plans can confidently plan and execute programs that deliver more value and improved outcomes. To learn more about Reveleer, please visit Reveleer.com.