
Contributor: The Stars Have Realigned (Again)—What Medicare Advantage Plans Need to Know
Understanding of changes in CMS' Star Ratings criteria will help Medicare Advantage plans to address all changes with confidence.
Medicare Advantage (MA) plans just saw 1 of the most significant drops in Star Ratings in recent years.
With the new year now underway, the annual challenge to earn a 5-star rating is back on. Once again, new and anticipated changes could have a massive impact on scoring. But with so many plans starting at a disadvantage, it is more important than ever to fully understand all the new expectations from CMS.
Here is an overview of what’s new, and advice for what MA plans should focus on in the coming year to maximize their chance of Star Ratings success:
1. The Tukey Outlier Deletion: Starting from the 2024 Star Ratings, CMS introduced the
“Although cut points will only experience the Tukey effect once—for the 2024 Star Ratings—and then should stabilize going forward, some MA plans dropped so far in certain measures that it will take years just to get back to where they were,” said Rex Wallace, CEO of Rex Wallace Consulting.
For this reason, a solid Stars strategy is critical, and plans may want to focus on
- Call Center - Foreign Language Interpreter and TTY Availability (Part D)
- Call Center - Foreign Language Interpreter and TTY Availability (Part C)
- Care for Older Adults (COA) - Medication Review
- Plan Makes Timely Decisions About Appeals
- Care for Older Adults (COA) - Pain Assessment
- MPF Price Accuracy
- MTM Program Completion Rate for CMR
2. Health Equity Index (HEI):
Eligibility for the HEI is limited to certain MA contracts based on the presence of members having specific social risk factors (SRFs), such as dual eligibility for Medicare and Medicaid, or enrollment due to disability. Qualified contracts must meet criteria regarding member numbers, SRF presence and comparative performance within the industry. The HEI score determines points earned, with contracts ranked and divided into thirds based on performance. Scoring above 1 will result in points added to the overall Star Rating.
As MA plans get acclimated to the HEI and anticipate its impact on their overall Stars performance, CMS has released contract-level reports that include, among several details, the subset of measures that may fall under the HEI. In preparation for success, it’s important for plans to understand their historic performance on these identified measures.
In addition, it’s critical to focus efforts on the 3 triple-weighted adherence measures for hypertension (RAS antagonists), cholesterol (statins) and diabetes. Within the Star Ratings, these measures have a
3. Quality Improvement (QI) “Hold Harmless” provision:
Depending on how it is finalized by CMS, experts agree the changes to the QI Hold Harmless provision (currently only
“The proposed change to the QI Hold Harmless provision will be the most substantial financial change that CMS has ever implemented. This change, coupled with the removal of the Reward Factor, will mean that EVERY plan needs to have a focused and detailed plan to manage QI performance throughout the year,” said Mick Twomey, CEO of Hyperlift.
Currently, the
Not only would this change the definition of a “high-performing” plan, it would challenge plans that currently rely on being “held harmless” to improve their Star Ratings performance. Plans will need a process in place to track performance on the 2 heavily weighted QI measures and keep this as a key focus of the Stars strategy to avoid the substantial negative impact of low performance on these measures.
A strategy for plans is to ensure they have a deep understanding of how the QI measures are calculated and establish processes that optimize performance. It will help to understand what the QI Significant Improvement thresholds may be for each measure and keep a focus on these when managing Star Ratings performance throughout the year.
4. Proposed Part D polypharmacy and opioid measures:
Originally
As
Plans will need to be sensitive in their member engagement approach in relation to these medications, as they are frequently used to manage pain and mental health. Working directly with the prescribing provider is 1 strategy to effectively address polypharmacy and safety issues in regard to the medications. Plans will also need to establish year-round monitoring of prescription claims, since members could be prescribed the medications at any point during the year and, as a result, qualify for 1 of the measures.
By incorporating year-round claims monitoring with a provider-first approach to outreach, plans will be able to strengthen the Stars strategy to address these polypharmacy measures in preparation for their finalization by CMS.
5. Shifting member experience weights:
Though
“Our guidance to MA plans is this: close your eyes to the member experience weight reduction. Pretend these measures are still 4x-weighted and do everything you can to continually improve them. At their core, no other measures are focused on access to care or the coordination of care. If members cannot access care, they cannot close a [Healthcare Effectiveness Data and Information Set] gap, nor can they pick up their medication refill. These measures are core to a sound Stars strategy,” stated Wallace.
Also, plans must acknowledge the interconnectedness of Stars measures, for example, the Getting Needed Prescription Drugs measure. This CAHPS measure may be experiencing a weight reduction, but continued high performance on this can also influence the plan’s performance on triple-weighted adherence measures, and therefore overall Stars performance.
Conclusions
In the coming year, the demand for MA plans to enhance their Star Ratings performance and maintain competitiveness in the Medicare arena is set to rise as CMS continues to update its criteria. MA plans equipped with a comprehensive understanding of evolving requirements, along with dependable partnerships for advice and assistance, will be primed to confront forthcoming changes confidently. With a deep understanding of ongoing developments—as well as trusted partnerships for guidance and support along the way—MA plans will be prepared to address any and all changes head on.
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