In Lewis Carroll’s Through the Looking-Glass, the Red Queen tells Alice, “It takes all the running you can do, to keep in the same place.” The government’s Star Rating clinical performance measures impose a similar situation for Medicare plans—the topic explored in a panel discussion during an October 18 session at the Academy of Managed Care Pharmacy (AMCP) 2017 Nexus in Dallas.
CMS has implemented a 5-star quality rating system for Medicare plans. The Star Ratings program is meant to incentivize continuously improved quality of care with bonus payments.
The ratings involve 48 individual measures in nine domains, each weighted for importance. (For example, patient experience and access to care measures are weighted by a factor of 1.5, whereas outcomes and demonstrated improvement are weighted by 3 and 5, respectively.) The end result is a single Star Rating of 1 to 5, with five stars being the best possible rating.
Bonus payments are a “carrot,” said Steve Cutts, PharmD, vice president of pharmacy services and clinical strategy at Magellan Rx Management in Scottsdale, Arizona. Plans earning 4 or 5 stars earn a 5% bonus payment. Bonus payments are intended to be invested back in improvement efforts to benefit plan members.
A “laser focus” on transparency also provides a marketplace “stick” because consumers can compare different plans’ CMS Stars Rating, he said.
The 48 measures range from basic processes like completing comprehensive medication reviews (CMRs) for beneficiaries to overall outcomes.
Star Ratings are a dynamic system—by design, their measures represent a “moving target,” Cutts said. That ensures that plans will invest in improved quality of care on an ongoing basis.
“The fundamental aim is to drive quality improvement and to reset the baseline from year to year,” Cutts explained.
Plan managers must anticipate shifting criteria because ratings for a given year are based on performance during a past year. The 2017 Star Ratings reflect performance in 2015, for example.
Because ratings depend on continuous improvement, it’s impossible to coast on past success. Maintaining success, like staying in the same place in the Red Queen’s race, requires a lot of effort.
“The status quo equals regression,” Cutts quipped.
“You have to stay ahead of the curve,” he said. “There are always new targets and you’ll find out how you’re doing only 10-12 months after the fact.”