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Maximize Value Infographics October 23, 2015

2016 Medicare Stars: A Tale of Two MA Plans & How They Achieved Stellar Results

VP & Chief Medical Officer for Medicare Products, BlueCross BlueShield of Tennessee
VP for Government Stars Performance Management, Highmark
Key Takeaway
Managing Stars performance is an evolutionary process - @Highmark VP for Government Stars Doug Fulton

Oliver Wyman Partner Jim Fields shares observations from his team's analysis of the 2016 Stars scores results and advice on how to improve scores from J.B. Sobel, VP & Chief Medical Officer for Medicare Products at BlueCross BlueShield of Tennessee, and Doug Fulton, VP for Government Stars Performance Management at Highmark:

Oliver Wyman’s proprietary Stars optimization model identifies Stars activity gaps and improvement opportunities with the highest impact and lowest cost. Three observations from our analysis of the 2016 Stars scores are:

  • Overall 2016 saw an average increase in plans’ raw scores of ~+3%, consistent with the 2015 trend. The average Stars score in 2016 was 3.74 Stars, compared with 3.64 Stars in 2015. Some 31% of plans experienced an improvement in their score from 2015 to 2016, while 52% experienced no change in their score.
  • Since 2014, the gap in average Stars score performance across plan types (i.e. Blues, Nationals, Provider-owned, or affiliated) has continued to grow. Provider-owned contracts have outpaced other contract types averaging ~4 Stars. Larger contracts have also performed better. To note, the average enrollment weighted Stars score in 2016 was 3.99 Stars compared with the non-weighted average of 3.74 Stars.
  • In 2016 the average Part C score decreased slightly, but strong performance on Part D was enough to maintain a positive trend in average Stars score. Plans struggled on clinical Part C domains (Staying Healthy: Screenings, Tests and Vaccines and Managing Chronic Long Term Conditions) averaging ~3.3-3.4 Stars. MTM, a newly introduced Part D measure, was the measure with the lowest average performance at ~2.3 Stars.

What It Takes

For advice on initiatives that can strengthen scores, we talked with the Medicare Stars leaders for two plans that achieved strong Stars score improvements for 2016:

  • J.B. Sobel, VP & Chief Medical Officer for Medicare Products at BlueCross BlueShield of Tennessee, which improved its Stars performance to achieve 4 Stars for 2016.
  • Doug Fulton, VP for Government Stars Performance Management at Highmark, which improved its performance to 4.5 Stars for its Western Pennsylvania contracts and improved to 4 Stars on its West Virginia contract.

Jim Fields: Your plan was able to achieve impressive improvement in your 2016 Stars score. Talk a bit about your 2016 score, the improvement over 2015, and whether your results achieved your goals?

J.B. Sobel (BCBST): Achieving a 4 Star designation is a big milestone for BlueCross BlueShield of Tennessee. It’s been a strategic focus of our organization for several years and in the past we were falling just short. For 2016, our HEDIS scores improved overall by 11%. We launched strong member outreach programs to give them control of their health and let them know we are with them every step of the way. This included using in-home service providers that bring needed healthcare to the member. We also provide assistance to our providers in identifying members that are in need of preventive services, and we have developed tools to assist caregivers in ensuring their patients get the care they need.

Doug Fulton (Highmark): We at Highmark are very pleased with our Stars results, having achieved 4.5 Stars for both Pennsylvania plans and 4 Stars in West Virginia. Moreover, we believe that this is a win for our members with 98% of our membership in 4.5 Star rated plans and the balance of our membership in a 4 Star MAO. Although we also had a strong year in 2015 reaching 4 Stars for our HMO and 4.5 Stars for our PPO in PA, we failed to hit 4 Stars in WV. Through a dedicated enterprise-wide effort, we not only were able to right our approach in the challenging West Virginia market, but we narrowly missed 5 Stars for both of our Pennsylvania products.

JF: How important was achieving your Stars goals to the Medicare line of business? To the company overall?

BCBST: BlueCross BlueShield of Tennessee places a lot of importance on quality of care and health outcomes for our members.  Reaching 4 Stars is important recognition that we are delivering a quality Medicare Advantage plan and network to all BlueCross members. But 4 Stars is not solely a Stars team achievement. We received support from many areas across our enterprise; making it truly a company-wide achievement!

Highmark: Achieving 4 Stars is table stakes, particularly in this very competitive MA market. It is paramount that we deliver quality care to our members at a competitive price year after year. A 4 Star rating across all Highmark contracts ensures that these goals are met. Highmark is uniquely focused on ensuring that our members continuously receive the highest quality of care and service that they deserve.

JF: What initiatives had the biggest impact on your Stars scores?

BCBST: Our member-based programs were critical. Encouraging them through education programs and communications to get into their doctor or go into their home when that is what the member needed. It required a portfolio of programs and a lot of coordination across them. Giving providers the data they needed to monitor the quality performance, gaps, and progress of their patients throughout the year made a big difference. Often the issue is not a lack of appropriate care, but simply a lack of documentation. The more we improve the information flow, the better the documentation can reflect the member’s health situation.

Highmark: The establishment of a dedicated Stars Quality Improvement Organization was one of the biggest drivers in achieving Stars success over the past two years along with executive sponsorship, which is absolutely critical to maintaining momentum across the organization. Highmark has invested in capabilities to enhance our operational performance, and partnered with providers to advance clinical quality outcomes and improve preventive care utilization. Through engaging members on the benefits of preventive care and partnering with providers to ensure delivery of these services, Highmark has increased the number of members receiving Annual Wellness Visits from less than 7% two years ago to an anticipated 35%+ this year. Concurrently, Highmark has heightened member satisfaction and engagement as demonstrated by our CAHPS results by simplifying member communications and ensuring each interaction with our members is without exception, best in class.

JF: What areas continue to be a challenge for your organization?

BCBST: In spite of our improvements, exchanging data with providers continues to be a challenge that we are working through and is something we see as an ongoing and iterative process. At least for the short term, ICD-10 will also pose some challenges with mapping to specific Star measures for both providers as well as Medicare Advantage plan sponsors. Lastly, evolving the model to engage members more face to face (such as comprehensive medication reconciliation or subjective HOS measures) is important to the continued success in member engagement.

Highmark: Management of Stars always has its share of challenges, regardless of whether or not a plan is achieving its goals. Industrywide performance continues to improve, which increases the threshold for success as health plans are graded on an industry curve. As a result, we are developing and implementing continuous improvement strategies across all areas of the enterprise both functionally and culturally. Furthermore, health plans “fly blind” throughout the course of a year, whereby the exact mix of Star measures and measure specifications that drive the rating are not fully known until after the measurement period closes and plans can no longer make an impact. Therefore, Highmark has developed predictive analytics and business intelligence to substantially increase the probability of success, which helps even when we lack certainty around the landscape. Finally, for several Star measures, we as a health plan do not have full control over the outcomes. Many times, it is the actions of providers and the perception of members that strongly contribute to the final scoring. However, we certainly can influence that performance in a variety of ways including partnering with providers, pharmacies, and other stakeholders to achieve outcomes that align with Stars goals.

JF: Stars is such a far reaching program (over 50 different measures spanning patient satisfaction to health outcomes). What did it take to mobilize the organization to achieve these gains?

BCBST: Executive leadership support was a huge factor in allowing us to achieve 4 Stars. Everyone from the CEO and Board, to the front line staff in the Senior Care Division, has been focused on achieving 4 Stars through improving member health and their overall experience.

Highmark: First and foremost, Senior Executive sponsorship is key. Secondly, it requires a clear understanding of the impact that Stars performance has on the organization both financially and competitively. In its corporate-wide communication efforts, Highmark took the technical complexity of Stars out of the communication, very simply explained the concept, CMS’ intent, the impact that the rating has on our organization both financially and competitively, and provided concrete demonstration of how each role across the enterprise has an impact on our performance. This awareness and education campaign ensured staff not only bought into Stars’ guiding principles and objectives, but internalized it. Moreover, it gave the Stars vision the appropriate attention it deserved throughout all levels of the Highmark enterprise. Highmark is uniquely focused on our members and we remind ourselves of that each and every day. We owe it to our members to ensure that we keep a meticulous eye on every aspect of the complicated Medicare Advantage operation to ensure continuous improvement and flawless execution.

JF: Any additional guidance you’d share on Stars?

BCBST: 4 Stars is only a milestone. Continued focus on the members' health outcomes and partnerships with the providers is what will be necessary to maintain our rating and continue to improve. We celebrated for a day and then kept looking for better ways to improve the health, quality of care, and experience of our members.

Highmark: Managing Stars performance is an evolutionary process. Past performance by no means implies future success. It is essential that we continue to press forward with newer, better, more effective and efficient initiatives to drive positive outcomes. The bar for success will only get higher each year as the industry improves. This is why it is so important to view Stars from a multi-year lens. Highmark has developed a long-term strategic roadmap which serves to guide all Stars-related strategies in the coming years. This includes building analytic and technological capabilities that will make us smarter and more efficient. It also ensures we identify and assign the correct resources to Stars activities and redesign our business processes to better manage all measures and supporting processes. In summary, the roadmap ensures we are constantly looking to the future so we can remain ahead of the curve and sustainably bolster Stars activities, and in a manner that does not come at the expense of near-term flawless execution.

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