Improve Your CMS Star Ratings

Star Ratings from the Centers for Medicare & Medicaid Services (CMS) directly impact revenue for Medicare Advantage plans. Higher ratings bring bigger quality bonus payments (QBP). Lower ratings can bring penalties and perhaps even termination.

Comprised of quality measurements for health and drug services, CMS Star Ratings hold plans accountable for the care that their members receive from physicians, hospitals, and other providers. The Overall Star Rating combines and averages the scores for all of the services covered. Consumers can thus compare plans on performance on quality of care when choosing plans. In addition to earning a larger QBP, a plan can increase its membership by improving its Star rating. Here are five ways you can increase your rating:

1) Plan your approach

Identify the quality measurements that you will report on and target those with the most potential impact. Assess each measure in terms of your ability to improve it and how it will affect your summary score. It’s often useful to divide opportunities into the immediately influenceable/lower cost initiatives and those opportunities that may take longer to realize improvement and are resource-intensive.

After you choose the measures to address, determine why you score lower in those areas and develop appropriate improvement initiatives. An effective approach is to construct improvement groups championed by clinical executive leadership to drill down to key drivers at the measure level. In many cases, a plan will find that there are common drivers across multiple measures; rather than focus exclusively on improving a single measure, the better alternative may be to influence multiple measures by addressing a common key driver of performance.

It is important that the improvement teams not get so large, as it may become difficult to gain group consensus. The intention of these improvement groups is to move quickly in categorizing the drivers of poor results. The teams should have appropriate representation related to data quality, member engagement and physician engagement relevant to the measure under review.

2) Focus on quality

Cultivate a “culture of quality” by educating team members throughout your organization on how Star Ratings are calculated and why they matter in terms that are relevant to departments and individuals and their responsibilities.

3) Engage members

Your members can also help you improve your scores when they take better care of themselves. Poor adherence to physician treatment plans, including prescribed medications, often hinder the quality of care, according to a HealthcareITNews article on engaging patients to earn higher CMS star ratings.

Member engagement strategies can help you increase scores related to member satisfaction and health outcomes, which are weighted more heavily in calculations for Star ratings. Effective strategies share the following traits, HealthcareITNews reported.

  • Plans use technology that transmits data like weight and blood pressure to monitor patients between doctor visits.
  • Members receive personalized guidance, including through means such as telephone calls from care providers.
  • Care-coordination programs optimize health outcomes by integrating treatment among multiple providers.

4) Reduce complaints

Disgruntled members can decrease your score by complaining to CMS about care, service or both. They could also leave you for another plan, thereby directly costing you revenue.

Enhance members’ perceptions of your plan by measuring quality and addressing satisfaction through steps like the following that an Ernst & Young consultant recommended in a Managed Care magazine article on how to boost your Medicare Star ratings and retain your customers.

  • Conduct parallel surveys and analysis, including yearly comparisons and adjustments based on Medicare Star ratings.
  • Incentivize providers to collect data at the member level.
  • Develop outreach-centered metrics.

5) Leverage data

Accurately measuring health outcomes and providing an auditable process that validates the care that members receive are essential in attaining high scores in the CMS 5-Star Ratings system. Consider investing in software that integrates clinical encounter data with your administrative healthcare data to more comprehensively measure plan, provider and member compliance.  

Then use clinical and risk identification algorithms to target members and providers who can help you increase your scores by improving care outcomes. Attaining your performance measurement and reporting goals will help you earn higher CMS bonus payments and attract new members.

Improving your CMS Star ratings requires you to develop and implement a cohesive strategy that will have your plan, its members and providers working together to deliver quality care and properly document the results. It is also important to watch for changes in the quality measures that are used to determine Star ratings, as they have evolved in the past and will likely do so again in the future.

Interested in learning more? Read our recent HEDIS and CMS Star Ratings related articles.

About The Author

Mike Curran is VP of Quality/HEDIS for Reveleer. He has worked in Managed Care for 25 years and brings extensive management and operations experience to Reveleer, as well as proven ability to build high performing, results-focused teams. Prior to joining Reveleer, he came from United Healthcare where he was the National Director for Clinical Performance Improvement. Mike is a graduate of St. Anselm College where he earned a degree in Politics and Boston University where he earned his Master of Public Health degree.