Reaching for the (CMS) Stars

Medicare Advantage (MA) health plans are ahead of the rest of the healthcare industry in moving toward competition based on transparent quality and pricing information, thanks in large part to the star quality rating system used by the Centers for Medicare & Medicaid Services (CMS).

Plans recently received their ratings for the 2014 enrollment period, and though average scores in MA as a whole have been increasing steadily, most plans still have room for improvement and need to plan for the next round of new (and higher) standards. What's the best way to improve star scores without losing your shirt? We suggest several key quality strategies in our report. And though they may require some analytic skill, in our experience, they are well worth the effort.

Provider Quality & Performance

The key to raising star scores is to identify the providers who actually make a difference in your scores — and the ones capable of delivering quality. The advantage of segmenting your providers is that it helps you identify providers to drop from your network, providers you want to steer members to, and providers you want to invest in improving. Of these three things, the one with the greatest, fastest short-term impact is dropping low performers from your network.

Reaching for the (CMS) Stars

Jim Fields and Martin Graf Answers 4 Questions
  • 1What is the secret to getting a high star score?

    When we analyzed this year's scores, the winning strategy was integration. Nearly all of the top-rated plans were owned by provider organizations, which meant that the doctors' interests were aligned with the payer's. The rest of the market, however, has really been left to find ways to improve the performance of diverse and often less-willing provider networks.

  • 2What is the first step toward a higher star score?

    Start with what's in your control. You can directly influence roughly one-third of the metrics that make up your star score, such as turnaround time on appeals. They aren’t weighted as highly as the clinical measures, but they are still significant. There is no excuse not to do well on these plan-controllable metrics. And in fact most health plans we work with are either receiving high scores in these measures or have an improvement plan with clear accountability under way.  

  • 3What action can have the most impact on ratings?

    Dropping low performers is one of the most important short-term steps you can take to improve your star scores. The trick is to figure out which providers in your network should be dropped altogether and which ones are worth a turnaround strategy. Some of these providers will respond well to the right sort of financial incentives and education, while others won’t, and still others will choose the goals of a different health plan over yours.

  • 4How should an MA plan prioritize?

    Rationalize your strategy for improving provider metrics. You can't afford to go after every CMS quality metric at the same time, and you wouldn't succeed if you tried. You need to choose the metrics where you can make the most difference in your final score (and your performance bonus) for the lowest investment. Stars can be a key tool for optimizing MA performance.