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Chasing a moving target: Keys to star ratings success


Opportunity abounds for plans that formulate the right stars strategy to capture bonuses and retain and win members

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.

Below: Watch a video interview with Snezana Mahon, PharmD, senior director of Medicare Solutions For Express Scripts, a pharmacy management benefit organization.


In addition, since star ratings launched, CMS has not forcibly terminated for performance … until now. Starting December 31, 2014 CMS will terminate MA organizations and stand-alone prescription drug plan (PDP) sponsor contracts that fail to achieve three star or better ratings in any Part C or Part D rating, three times in three consecutive years. More than 37 CMS contracts for MA prescription drug and PDP plans are in the cross hairs today-creating significant business issues for those contract holders, but also potentially releasing 1.1 million Medicare members back onto the open market as of January 1, 2015.

Taken together, today’s stars changes mean that, while the path gets rough, opportunity abounds for plans that formulate the right stars strategy to capture bonuses and retain and win members.An ever-changing landscape: More change ahead 

While some plans may experience “make or break” performance situations, all plans face perhaps the greatest challenge: keeping up with changing star measures. Even four-plus star plans may feel they are working toward a moving target. 

For the upcoming 2015 ratings, CMS added a new Part C measure, made changes to seven of the current measures and retired another Part C measure. These changes mean that even strong plans cannot rest on past performance-ALL plans must adopt a continuous improvement mindset. For example, for 2015, metrics established for flu vaccines and diabetes medication adherence will have a favorable to neutral impact on a plan, while measures related to special needs care management and pharmacotherapy management of chronic obstruction pulmonary disease will be far more challenging.

In 2016, elimination of defined four-star thresholds in favor of a 'clustering' methodology for determining scores means that plans are not just aiming at aggressive metrics, they’re chasing a moving target that works essentially like a bell curve.

Data is the key to building a plan

Looking across Express Scripts’ Medicare MAPD and PDP business, and across the industry, the high-performing plans are the ones that systematically develop, execute and refine strategies to keep up with changing performance measures. The bedrock of their strategy is data. If building strong stars is a thousand-step journey, know your data is the first one, the last one and quite a few in between.

Because we work with many regional and national plans, we can identify common characteristics among high performing plans:

  • Strong plans use every tool at their disposal. This includes plan data, government and member surveys, and industry research data from both traditional and non-traditional sources;

  • The best plans dig deep. If they learn something from one data set, they dig deeper to turn multiple data points into meaningful insights; and

  • Successful plans steer clear of assumptions. The factors driving issues with one-star ratings are not necessarily what’s causing issues elsewhere.

High performing plans-and those that aspire to be-should use traditional sources (like CAHPS member survey, and ACUMEN) and non-traditional data sources (benefit and drug trend data, and industry studies like the 2014 AGING SURVEY). 

From there, the best plans dig deep until they have enough insights around the four key cluster areas that ultimately drive most star ratings metrics: Member experience, member perception, member outcomes and member/provider decisions. For example:

  • Around member outcomes: How are you aggregating medical, pharmacy and lab data to paint a full picture of your member health? Are you systemically reviewing member health records and clinical tests, preventative screenings and recommendations against medical and pharmacy data? 

  • Around member perception: With CAHPs, beyond just the scores, how well do you understand patterns with gender, age and location? Conditions? Clinical program use and frequency? Communication and engagement? 

Use data to drive impactful change

Data should also help you define the most effective and efficient stars improvement strategies. Plans have limited resources, so it’s best to target efforts against moving measures that have the greatest impact to overall ratings and resulting financial reimbursements. Healthcare informatics teams and solutions, such as Express Scripts’ CONSTELLATION RATINGS ADVISOR, can help plans maximize their star ratings performance strategy.

Having both short- and long-term strategies is also important. For instance, back to CAHPs: Let’s say a plan wants to improve these survey responses:

  • How often did your plan's customer service give you the information or help you needed about prescription drugs? 

  • In the last six months, how often did your plan's customer service staff treat you with courtesy and respect when you tried to get information or help about prescription drugs?

In the short term, the plan might share CAHPs survey results within the organization and better educate service teams about why member experience matters. In the longer term, the plan might consider bigger ticket items such as implementing an employee incentive programs around stars improvement, or implementing social media channels to reach and educate members (and the caregivers supporting them) on simple ways to improve their health.


Organizational alignment matters

Once goals are defined, the next challenge is to drive organizational alignment around star ratings. Successful plans will:

  • Get executive buy-in at every level;

  • Ensure there’s a financial commitment focused on the member experience and health outcomes;

  • Coordinate actions with members and providers to drive positive change and break down silos; and

  • Build the plan to drive alignment, actionable prioritization and accountability.

The most important steps high-performing plans can take are to remove the silos and incent what matters most to make the organization accountable. For instance, when we conduct star ratings summits with clients, we strongly advocate for having all relevant parties there-including pharmacy and quality but also strategy, customer service, operations, compliance, marketing-even IT and finance.

Ultimately, a star ratings strategy is a Medicare plan management strategy. Actions to improve member perception, experience, outcomes and decisions is cross-functional by nature, so governance structures and incentives must be as well, requiring significant dialogue and alignment. Just think about customer service: Agents can push up your scores in hidden places (e.g. preventative care reminders) or pull them down (e.g. poor member interactions). Everything is a push forward or a step back.

Final steps for success

Because this process can be complex, consider the following checklist as a way to help prioritize the direction forward and to chart a winning stars strategy over the next year.

  • Understand historical performance and where to set your sights next, by deeply analyzing both traditional and non-traditional information sources;

  • Set short- and long-term goals, and build a roadmap to get to where you want to go;

  • Identify the short-term actions you can begin improving today, and the “big lift” high-impact actions that will, over time, drive the total plan performance you need;

  • Determine a master plan to embed in your organization that will make changes sustainable; and

  • Identify how you will measure and adjust your plans going forward.

While the updated 2015 October ratings will let you assess where your plan stands today, what’s most important is that you make a game plan to ensure your path forward for both short-term and long-term improvement based on data, and measured each step along the way.



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