Three ways to build a smarter Stars strategy

Recent changes to how Centers for Medicare and Medicaid Services (CMS) Star Ratings are calculated-  particularly the removal of the pre-determined thresholds-have many plans feeling like they are in a race, constantly looking over their shoulder to see who’s right behind them, and worried about how to stay ahead or take the lead.

Five-star cut points are shifting, and plans will not know which ones will adjust. Additionally, 2016 MA-PD Star cut points for categories such as diabetes adherence, high-risk medications and appeals are aggressive and will be a challenge for plans to achieve.

Related:CMS' rewards programs can impact Medicare Advantage

Plans are currently performing well; nearly half of all MA-PD plans earned four or more stars in 2016. But how can plans keep maintaining this performance in the midst of this race?

Data analytics strategies for Star Ratings success

Mahon, PharmD

The answer is in knowing how your plan is performing in relation to your competition, including the 188 new plans in the marketplace that are not yet rated, and how those variables will affect the curve in 2017.

In our view, the following three data strategies-which are highly targeted and actionable-are important to a successful Star Ratings strategy.

• Retrospective data. Most plans already use Retrospective Drug Utilization Review Data (RDUR), Acumen data, PBM data, and medical claims data every day. If you’re not, you must maximize use of these resources, looking under every rock to see what is the data are telling you and NOT telling you. For example, ACUMEN data is good; however, it is not real time and only provides population-level information. Plans should have their analytics team mine the data from a population level down to the member level and use those insights to drive member specific interventions. Also, how are you bringing all of these data sources together to fully understand the comprehensive picture of your current gaps-in-therapy, over- or under-utilization of therapy?

• Data informatics. Data is not useful unless plans are able to easily identify patterns and opportunities for improvement. The goal of data informatics is to help simplify the terabytes of data available to a plan and make it usable. A recent example of a data informatics solution is an Express Scripts tool called MediCUBE, which simplifies most of the inefficient aspects of data mining and allows users to uncover insights about members, prescribers and pharmacy networks- quickly and effectively-with the ultimate goal of controlling costs and increasing profitability of medical and pharmacy benefit programs.  MediCUBE synthesizes a proprietary database of 11 billion prescription claims and four billion medical claim records for more than 180 million patients linked to more than four million unique healthcare providers. With it, plans can go beyond book-of-business reporting and see prescriber and utilization patterns that were not available to them before.  This allows plans to pinpoint intervention opportunities at the member, prescriber and pharmacy level.

• Jawar, PharmD, MBA, CGPPredictive analytics. Now that four-star thresholds have been removed, plan performance is largely impacted by competing plan performance. Predictive data analytics can help a plan understand what its performance will be at the end of the year, and when coupled with benchmarking data, it can also show how a plan’s performance measures against the competition. For example, Express Scripts’ Constellation Ratings Advisor tool provides plans with a customized model that keeps up with changing CMS regulations and can identify areas where plans can boost Star Ratings performance and maximize Star Ratings reimbursements with real bottom-line impact. Managing prescription medications for a quarter of the Medicare market, our clients can use this information, which is built into Constellation, as a valuable benchmark for how their plan will perform against others in the marketplace.

 

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