Introduction
How CMS Star Ratings are assessed
The Centers for Medicare & Medicaid Services releases its quality Star Ratings each October to be applied to the next calendar year. Star Ratings show how well a Health Plan performs on specific things. The star rating system assesses health plans based on various factors, including preventive care, chronic disease management, member satisfaction, customer service, and overall member experience.
These factors are often categorized into different domains, each carrying a specific weight in the overall rating. Health plans are assigned star ratings on a scale of 1 to 5, with 5 stars indicating excellent performance and 1 star indicating poor performance. These ratings are a valuable tool for consumers when selecting a health insurance plan, as higher-rated plans are generally associated with better quality of care and customer service.
Star Ratings & Risk Adjustment
More than 24 million Americans are enrolled in the Medicare Advantage plan, a number that has doubled in the past ten years and is anticipated to increase substantially by 2030. The Medicare Advantage Star Ratings system comprises 42 measures categorized into several distinct categories, each assigned varying weights.
2024 star ratings: The Lost Advantage and incumbent corrections bring new equilibrium
During the October 2024 star ratings release, several health plans fell short of expectations, attributed to the exclusion of COVID-19-induced adjustments intended to support Plans during the pandemic, along with applying the Tukey outlier deletion method.
CMS sets standards for five-star plans by carefully analyzing their performance and how it compares across different areas. They use this information to determine specific points where they draw the line between different rating levels. Tukey’s job is to remove any unusual data points that could throw off the ratings, which might cause the cutoff points to be set a bit higher.
As Tukey’s adjustments are implemented over the next few years, we might see some ups and downs initially, but things should even out by around the third year.
Understanding Medicare Advantage Star Ratings
Before exploring risk adjustment strategies, it’s crucial to comprehend how risk Adjustment factors contribute to MA Star Ratings.
- CMS assesses MA plans by considering various quality measures within five domains:
- Staying Healthy: Highlights preventive care services and screenings.
- Managing Chronic (Long-term) Conditions: Focuses on effectively managing chronic diseases.
- Member Experience with Health Plan: Evaluates enrollee satisfaction and customer service.
- Member Complaints, Problems Getting Services, and Choosing to Leave the Plan (also known as Complaints and Changes in the Plan’s Performance): This section reflects enrollee grievances and plan performance.
- Health Plan Customer Service: Assesses the responsiveness and effectiveness of customer service.
Each domain has a specific weight, and plans receive ratings on a scale of 1 to 5 stars, with 5 representing the highest rating.
A higher Star Rating indicates better quality and offers plans competitive advantages and financial incentives.
Risk adjustment – An important quality measure for Medicare Advantage (MA) plans.
Risk adjustment is a crucial component of MA payment methodology designed to compensate plans for their enrollees’ health risks accurately. It ensures that plans caring for sicker populations receive adequate funding to provide Quality care and necessary services.
However, the accuracy of risk adjustment is paramount. Inaccurate risk scores can result in underpayment or overpayment, impacting the financial stability of MA plans and the quality of care provided to beneficiaries. Therefore, implementing effective risk adjustment programs is instrumental in optimizing Star Ratings and ensuring fair compensation for plans based of care quality.
CMS Star Ratings under the Influence of Risk Adjustment
Risk adjustment has the potential to increase Star Ratings by addressing care disparities. The crucial aspect is to enhance quality care gaps, and concerning risk or value-based agreements, it’s crucial for a healthcare plan to have a clear direction.
A successful and crucial risk adjustment strategy involves prioritizing the recapture of chronic conditions annually. This guarantees consistent communication with healthcare providers to oversee and treat chronic conditions for enhanced care quality. It also ensures equitable reimbursement for healthcare plans offering MA, commercial, or Medicaid products.
Effective Risk Adjustment Strategies for Medicare Advantage Star Ratings
Risk adjustment strategies play a crucial role in attaining superior Medicare Advantage Star Ratings by ensuring that the ratings accurately reflect the quality of care provided to beneficiaries and account for differences in the health status of the enrolled population.
Here’s how these strategies contribute to achieving higher Star Ratings
AI-Enabled Accurate Assessment of Risk: Arguably, the most noticeable trend is the recent finalization of the Risk Adjustment Data Validation (RADV) rule by the U.S. Centers for Medicare and Medicaid Services (CMS), which has heightened regulatory scrutiny on healthcare entities to guarantee precise risk adjustment. The rule aims to facilitate CMS reclaiming overpayments to healthcare entities granted due to flawed risk adjustment. Hence, it is imperative to use precise cNLP to identify clinical conditions and their supporting evidence (in line with the Monitor Evaluate Assess Treat – MEAT framework).
Additionally, the Medicare Advantage risk adjustment model will transition from V24 to V28 within the next three years. These modifications will substantially reduce the array of risk-adjusted conditions; thus, technologies facilitating accurate and comprehensive capturing of a member’s health data become imperative for organizations striving to safeguard the necessary funding for caring for their chronically ill members.
NLP can search through clinical documentation to locate denominator and numerator criteria within unstructured medical records for quality programs like HEDIS. For instance, this includes identifying patients who underwent fall screenings or mammograms has a direct bearing on improving STARS ratings.
Optimized Care Management: By clearly understanding the health risk profile of their enrolled members, healthcare providers can tailor their care management programs to meet the specific needs of each individual. This might include proactive outreach, preventive care services, chronic disease management, and medication adherence programs. By addressing health issues before they escalate, providers can improve health outcomes and overall satisfaction among beneficiaries, increasing provider ranking.
Enhanced Documentation and Coding: Enhanced documentation and coding are critical in improving star ratings for MA health plans by facilitating accurate risk adjustment, identifying relevant quality measures, maximizing reimbursement, supporting quality improvement initiatives, and promoting provider collaboration.
Quality Improvement Initiatives: Quality improvement happens through holistic care coordination and member education, which helps identify areas for improvement and track progress over time. Leveraging coordinated efforts helps in decision-making and effectively targets interventions, thus, MA plans can demonstrate continuous improvement in quality metrics, reflected in their star ratings.
Data Analytics and Predictive Modeling: Advanced data analytics and predictive modeling techniques enable healthcare providers to identify high-risk patients and intervene early to prevent adverse health events. By leveraging Clinical AI-based solutions and suspect analytics, providers can identify patterns, trends, and risk factors that may impact patient outcomes.
Moreover, as part of its mandate to improve the accuracy of Star Rating measures, CMS gives considerable weightage to social determinants of health in calculating risk scores as per the recent risk adjustment model applicable to Medicare Advantage plans.
This proactive approach allows for targeted interventions and resource allocation, ultimately improving the overall quality of care.
Collaboration and Integration: Risk adjustment strategies encourage collaboration and integration among healthcare providers, insurers, and other stakeholders within the healthcare ecosystem. By sharing data, Interoperability best practices, and resources, providers can deliver more coordinated and comprehensive care to Medicare Advantage beneficiaries. This collaborative approach fosters continuity of care, reduces redundancies, and improves the overall patient experience.
Challenges
As each new year approaches, healthcare plans face more changes in how they’re evaluated with Star ratings. One big change for the 2024 ratings is the introduction of the Tukey method banister.
This basically means that extreme performance results won’t count as much, making it harder to get top ratings. Also, this time, the focus is less on how patients feel about their care and more on the medical and pharmacy aspects. To do well, health plans need to get patients and doctors more involved, using different communication channels and being more active in local communities, which hasn’t been a big deal before. Even though providers are trying hard to improve medical and pharmacy measures, it might not have as much of a positive effect on their ratings as it did before when it was all about the patient experience.
Future Outlook
The MA industry has survived and flourished when significant risk adjustment model changes have been made. In recent times, Plans have experienced past years of lower growth in capitation rates, but membership and supplemental benefits have consistently increased. Membership in dual and non-dual MA plans is healthy and growing, and the number of organizations offering MA plans has increased. It is an exciting time to be part of an industry reshaping healthcare in our country!
What remains to be seen is how swiftly plans can adapt to these new rules and improve their Star ratings by leveraging risk adjustment as a force multiplier to their overall quality programs.
Frequently Asked Questions (FAQ)
CMS releases its quality Star Ratings each October based on hospitals’ performance in various areas like preventive care, chronic disease management, and member satisfaction. These ratings give an overall idea of how good the care is, with five stars meaning excellent and one-star indicating room for improvement.
CMS plans to introduce a new risk adjustment model over the next three years, using more codes to calculate risk scores but reducing the number of diagnosis codes affecting these scores. This change is due to an update from using ICD-9 to ICD-10 codes.
Reports suggest that CMS may have overpaid Medicare Advantage plans by $75 billion in 2023. With stricter government oversight in the coming years, plans need to ensure the accuracy of their risk adjustment data.
Risk adjustment ensures fair compensation for plans based on their members’ health risks. By optimizing risk adjustment efforts, MA plans can improve their Star Ratings and ensure fair compensation for quality care.
Introducing the Tukey method banister means extreme performance results won’t count as much, making it harder to achieve top ratings. Additionally, the focus is shifting from patient experience to medical and pharmacy measures.
Providers can focus on optimized care management, enhanced documentation and coding, quality improvement initiatives, data analytics, and predictive modeling. Collaboration and integration among stakeholders are also essential.
The Tukey method banister reduces the impact of extreme performance results, making it more challenging to achieve top ratings. This change emphasizes the importance of improving medical and pharmacy measures.
Providers should focus on engaging patients and providers, improving documentation and coding practices, implementing quality improvement initiatives, leveraging data analytics, and fostering stakeholder collaboration.
Despite challenges, the MA industry has flourished, with a growing membership and increased offerings. It remains crucial for plans to adapt to new rules and leverage risk adjustment to improve Star Ratings and overall quality programs.
