The U.S. Centers for Medicare and Medicaid Services' (CMS) FIVE-STAR QUALITY RATING SYSTEM has been in place for years, but never have its implications been so important—both for plans to capitalize on opportunities and avoid falling behind. The financial impact of star ratings has been substantial for a while, but with today’s changes, the lack of a smart stars strategy is detrimental to the health of the plan itself.
A great deal is changing. First, as every MEDICARE ADVANTAGE (MA) plan in the country now knows, the CMS “pilot” program to incent improved performance is changing. After rewarding MA plans with “high performance” (defined as three stars or above) for years, CMS is now reducing Quality Bonus Payments, and even eliminating bonus payments, for plans with fewer than four stars. The pilot was one of the biggest changes to Medicare as a result of the Affordable Care Act (ACA), and it’s working: MA plan scores are on the rise. However, the impacts to three and 3.5 star plans are significant—affecting not just profits, but their ability to reinvest in driving the “virtuous cycle of success.” This means:
Plans must continually invest in programs that will engage and support their members;
Each member will maintain or improve their health and well-being; and
- Plan members have the kind of positive experience they want to share with others.