CMS Star Ratings are do-or-die for health plans. And this year, the bar is higher than ever. Star Ratings are critical for Medicare Advantage carriers. For many, the 5 percent reimbursement bonus for four- and five-star contracts determines whether or not the plan will turn a profit. As ongoing regulatory changes and competitive pressure make high ratings even harder to achieve, plans must understand exactly where and how to invest in their performance to maximize impact and ROI.
Almost twenty percent of the evaluation criteria for determining Part C Star ratings is comprised of metrics traditionally viewed as explicitly payer-driven. And—given a greater perceived ability to impact—many payers have traditionally focused in on these consumer-centric member experience measures.
But in practice, our research has found, scores are determined almost entirely by the performance of contracted physicians rather than the payer itself. The chart below illustrates the point: there is a nearly perfect correlation between county average Part C Star ratings for all measures vs. provider-driven measures only (e.g., clinical quality / outcomes). The conclusion: success on Stars starts and ends with your provider network.
Provider-driven measures—and the network of physicians who influence them—are where plans must focus their energy and investment. Payer-driven member experience measures are still important (they make up roughly 17 percent of the overall Part C scoring weight 7) but are secondary to clinical quality.
Interestingly, clinical quality may even affect scores on the member experience measures—the metrics traditionally viewed as payer-driven. There is a meaningful correlation between average scoring on members’ “Rating of Health Care Quality” and “Rating of Health Plan”. Patients tend not to distinguish their experiences with their doctor from their experience of their health plan—so that what happens in the physician office shows up in the payer-driven measures.
There is no one-size-fits-all approach to driving clinical Stars performance. You need to make some hard choices – choices made even harder by the uncertainties of the evolving scoring system. You have to understand your network, your market, and the full range of tools you can deploy – from incentive programs to in-office intervention to network sculpting.
If there is one thing we’ve learned in our work with health plans and their quality improvement strategies, it is the importance of taking a long view. Stars is just the beginning—comparable quality programs are proliferating in other managed care markets (exchange, Medicaid, etc.) with increasingly weighty financial implications. Continuous quality improvement is not a now-and-again concern; it is one of the cores of your business.