Nearly half of Medicare Advantage with prescription drug coverage plans (MA-PD) earned 4 Stars or higher in the CMS 2017 Stars Ratings. That’s up from 37 percent in 2014. Pittsburgh-based Highmark and BlueCross BlueShield of Tennessee earned strong ratings for the second straight year. Here, J.B. Sobel of BCBS Tennessee and Doug Fulton of Highmark share lessons from their journey to Stars success.
Oliver Wyman Health: Individual quality initiatives are impactful, but achieving 4+ Stars requires a coordinated approach and cultural commitment from the organization. How did your organization create that cultural commitment and what advice do you have for other plans?
Doug Fulton: In order to achieve 4.5+ Stars for large HMO and PPO products year-over-year, the health plan must have a unique focus on continuous quality improvement. Senior executive sponsorship is paramount in maintaining focus. After that, it requires individuals who are willing to look at challenges as barriers that must be quickly maneuvered around. This one-two punch of sponsorship and an unrelenting quest to be best in class demonstrates leadership to the enterprise that leads to a cultural commitment from all who support.
J.B. Sobel: Key for us was a true enterprise commitment – from the Board down through leadership, which, in turn, encouraged a focus on health outcomes for our members in all business segments. Also critical was an experienced leadership team that understands the Medicare landscape and how this differs in approach from other insured lines of business.
OWH: Data is so foundational to Stars success (everything from the appropriate intake to finding new and novel ways to obtain and share it with your business partners). What have you done to ensure you have good data and measurement tools?
DF: Without strong analytic tools, health plans are leaving their performance to fate, but actual Stars performance data are a lagging indicator of success. To overcome this, health plans must invest in strong forecasting capabilities, and (most importantly) leading indicator performance data that will allow plans to course-correct throughout the 18-month Stars performance cycle. Over the last several years, Highmark has developed a robust data processing engine of closed-loop analytics that can predict areas of concern given year-to-date performance, comparisons to prior years, and required targets for each measure. These investments have been and continue to be the foundation to our ongoing success.
JBS: We developed an internal scorecard solution that is calibrated to match CMS data, as well as a variety of sophisticated predictive analytics to drive outreach to members on areas from medication adherence to readmissions. We also compiled member attributes into a central repository for consistent, easily attainable data for reporting and analytics. We use external integration partners to ingest, clean, and format provider EMR data, and have invested in bi-directional data sharing with providers to enable improved health outcomes at the point of care.
OWH: How do you balance your efforts across measures that are provider driven vs. those that are plan driven?
DF: Many in the industry believe that provider-driven performance is the key to success. While Highmark agrees that is very important, it is not the silver bullet in a maturing market. Highmark believes that health plans must absolutely optimize performance on measures in which health plans have a higher degree of control over the outcomes, because the preponderance of the provider- and member-influenced measures are based upon statistical samples, which can be highly volatile. In other words, Highmark views these plan-driven measures as a means to reduce the unpredictability in overall health plan Stars performance, year-over-year.
“Health plans that have been investing in core competencies and creating aligned long-term partnerships are much better positioned to achieve a higher degree of success.”
JBS: Every measure is, obviously, important to the final rating. Periodic touch points are utilized to monitor and adjust plan efforts relative to specific measures. A provider-focused strategy is developed annually, and the Provider Outreach team prioritizes outreach/education based on attribution and current performance within the provider practice.
OWH: Now that the Stars program is more mature and the rules of the game are known, what is next in terms of optimizing performance?
DF: Those health plans that have been increasing efficiencies by investing in core competencies, insourcing, and creating aligned long-term partnerships with providers and vendors are much better positioned to achieve a higher degree of success year-over-year at a lower investment point. This is creating more competitive price points from vendors who provide more specialized Stars services. That said, many of these smaller vendor/partners are still not willing to take on Stars risk in order to obtain or maintain the business. We believe that this will change in the years to come. The Stars industry will be an interesting thing to watch over the next few years; we see it changing for the better.
JBS: I would say transforming from fee-for-service to value-based provider contracts, which over time aligns provider outcome goals with the payer, and allows more focus on members/patients and their health outcomes. Also, finding different ways to communicate and engage members (such as SMS messaging, email or in-home visits) to improve their health status and comply with their doctor’s plan of care. Finally, fine-tuning member incentive programs to maximize compliance with recognized screenings that are the underpinnings of the clinical portion of the Stars program for MA.
OWH: What initiatives have you seen be most impactful to your success this year?
DF: Highmark has developed a unique set of capabilities to better engage members, pharmacies and providers across the spectrum of care with respect to Med Adherence. As part of our efforts, we have found that the barriers to adherence are often non-clinical in nature. Specifically, access to pharmacies, physicians, and/or economic challenges are often the primary barrier to adherence. Highmark has created an analytics model identifying who will likely become non-adherent, as well as member willingness to engage and through what channel. This has driven our Med Adherence performance higher year-over-year for the past several cycles, which is so important to the overall health plan Star rating considering that these three measures are all triple weighted.
JBS: Each of these played a role in our success:
- Personalized member scorecards, which go out to all members twice annually and highlight gaps open and closed along with health and wellness information.
- Expansion of electronic clinical data exchange for lab and EMR data.
- Tiered reimbursement for providers completing a Provider Assessment Form (PAF).
- Quality Outcomes agreements coupled with value-based contracting for providers.
- Insourced, dedicated member outreach team staffed with both customer service representatives and pharmacy technicians.
- In-home vendor options for HEDIS gaps to supplement in-office testing.
OWH: What surprised you in this year’s scores?
DF: It is interesting, that although the number of health plans that reached 4+ Stars over the last two years has remained relatively flat, the players who have reached 4 Stars have changed. Many Blue Health Plans and non-profits have been gaining significant ground over the last couple of performance cycles, and some of the very well capitalized, for-profit nationals have seen a drop in performance. It will be interesting to see if some of these for-profits can change this trajectory or not. Either way, given the strong performance across the industry over the last few years, we expect that CMS will begin to change the standards of performance in relatively short order.
JBS: We did not anticipate the 3- and 4-Star cut points for the medication adherence measures to change as drastically as they did. Also, we were able to benefit from excluding the quality improvement measures from the final calculation of the overall Star ratings, for already high-performing plans.