As every Medicare Advantage (MA) plan knows, the CMS’s annual Star ratings play a critical role in their financial viability and future — including the ability to grow their network, increase market share, and expand their service area.
As critical as they are, these ratings are a moving target. With standards changing year over year, the bell curve, and delayed results, plans are at the mercy of an unpredictable system. Star ratings have evolved from check-the-box measures that are simple to institute and track to complex, outcomes-based measures that are difficult to impact. For example, the number of Health Effectiveness Data and Information Set (HEDIS) measures and relative measure weight has decreased, while more emphasis is placed on Consumer Assessment of Healthcare Providers and Systems (CAHPS). This shift indicates that CMS is focusing on outcomes-based measures, including Patient Experience, Medication Adherence, and Transitions of Care.
To keep up with the pace and complexities, MA plans are in an ongoing race to innovate and adapt to an ever-changing environment. Yet many still use models and strategies from the simpler Star world of a decade ago, making it more difficult to keep up with the shifts.
Recent CMS Changes Add to The Challenge
Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience measures remain critical to plan performance—especially when considering their impact on the improvement measure. Plans need to understand what a positive customer experience means to their members, and what drives member behavior to close gaps in care. Despite dedicated efforts to tackle this issue, plans are often overwhelmed by a deluge of customer voice data and lack the resources to analyze and apply it to their Star strategy in meaningful ways.
Given these complexities—not to mention the current healthcare environment—how can your MA plan grow by continuously improving its Star ratings?
For all MA plans, but especially those that rely on old models and strategies, 2023 may be an especially tough year. Here’s why:
- CMS no longer allows for “better of” methodology—an allowance that was granted due to the pandemic.
- Tukey outlier methodology will make cut points more challenging, making it harder to maintain or improve performance.
- New Past Performance criteria means that Star ratings will impact your ability to enter into contracts and expand service areas.
- The proposed Health Equity Index will create new incentives for MA plans to eliminate health disparities.
- The CMS Proposed Rule released in December 2022 recommends CAHPS patient experience measures return to a 2X measure weight in MY2024.
The Power Of Behavioral Science Combined With A Multi-Year Perspective
To best position your plan for the next few years, we recommend taking a long-term perspective and adopting some basic behavioral science methods to advance your rating. This may require a shift in mindset and practices to be less reactive and more proactive as Star ratings evolve from year to year.
- Get measurable success with behavioral science. We’re bringing behavioral science to the forefront of MA plans in ways that can have a positive impact on their Star ratings. We use a framework made popular by Stanford professor, BJ Fogg, that connects three elements that must happen for a behavior to occur: motivation, ability, and a prompt. To change behavior, you need to evaluate all three. First, what is motivating and demotivating your members toward an action?
- Second, do they have the access and the ability needed to do what we’re asking them to do?
- Lastly, are we giving them sufficient prompts or reminders to act?
Using this approach to drive better member outcomes can also improve your rating since Star ratings are linked to the member’s experience and health. It takes patience and consistency to impact your Star ratings. For example, it can take up to four years for MA plans to see the Star rating impact of a new program they’ve invested in. Executives often pull the plug on promising programs after getting short-term MA stars results that failed to meet their expectations. While this may be the right response in some cases, in others it’s a knee-jerk reaction leading to a series of “whack-a-mole” initiatives to improve next year’s ratings—which fail to meet expectations once again. Rather than adopting short-term, reactive initiatives, we recommend taking time to understand member needs and staying focused on building the best experience as the best way to drive Star ratings.
This requires a customer-centric rather than a process-centric approach where you’re consistently asking for feedback, learning, and testing new ways to engage your members.
By evaluating member behavior through this lens, we can easily identify key barriers and design tactics and experiences to overcome them.
For example, if an MA plan is struggling to get people to sign up online, we need to identify the core barriers. Is the process is too long or confusing, leading members to abandon sign-up midstream? Or perhaps they forget because they aren’t prompted at a time that’s convenient to follow through? By identifying barriers, we can then develop the right tactics, such as auto-filling fields or tying sign-up to another task they’re already doing.
This delayed rating cycle calls for plans to take a multi-year perspective. Think forward. Look at what CMS is proposing for future years, and work backward to understand where the member is going and how their needs are evolving.
For example, CMS indicated through their HEDIS measures and recent advance notices that health equity is going to become a larger component of the overall Star ratings going forward. Get started now to:
- Ensure you are collecting social determinants of health (SDOH) data
- Analyze your data to understand where and when equity breaks down
- Create opportunities for cross-functional collaboration within your organization, including customer experience, contracting, provider relations, Stars, pharmacy, and other key groups.
- Determine your engagement strategy
- Design tactics
- Execute, measure, and refine
Whether you’re considering or already decided on metrics and KPIs, ask yourself:
- What are your 1-, 2-, and 3-year targets for specific areas of the Star rating?
- Are there process-related measures or internal metrics you can track outside the actual Star rating for that measure?
- Will you launch studies for any new programs? Have you established a meaningful evaluation method?
- Are you building the ownership you’ll need from key stakeholders across your organization?
- Most important, do you have leadership’s buy-in to stick with the program and support the change and stakeholder management that’s essential to success?
What To Watch Out For
On the path to higher Star ratings, there are many costly and time-consuming distractions that prevent forward momentum for your plan and your members. It’s just as important to consider what to avoid as it is what to adopt and act on. Here are a few considerations:
The technology landscape is not a promised land. Technology plays a major role as MA plans become more data-driven and focused on member experience. But be careful. The rapid proliferation of vendors and options has led to false promises, bad implementations, and major distractions.
Technology is no substitute for knowing your current and future membership and optimizing operations to encourage healthy behaviors. For example, if your member population is not a digital-first demographic, it may not make sense to invest in an app when they’re craving more live interaction. And if you do, you’ll need to focus on training your members, a resource-intense proposition. The moral of the story is that it always comes back to understanding member needs before focusing on operational efficiencies.
Technology is no substitute for knowing your current and future membership and optimizing operations to encourage healthy behaviors.
Resist the temptation to be reactive. It takes time to reap the rewards of many improvements that will elevate your Star rating. A single year of investment is unlikely to deliver the value you’re looking for in the timeframe you’re hoping for. As a result, it can be tempting to start tinkering and “fixing” things that don’t address the underlying issues.
Consider ways you can become less reactive and more proactive. Act now to deepen your knowledge and connections with your members, which will make introducing new plans easier. Know your providers and find new ways to strengthen mutually beneficial partnerships. Get to know and use the basic motivational methods of behavioral science so you can apply them when and where they can make a positive impact.
A simple way to get started is to develop a member community you can reach out to on a regular basis for feedback. This will help you gauge interest and understand the success potential of new initiatives before you invest in them.
Improving Health Improves Your Stars Rating
While elements of MA Star ratings change every year, we encourage our clients to align continuous quality improvement efforts with multi-year trends. CMS has signaled a move toward rewarding three major interrelated goals:
- Growing member satisfaction
- Measurable gains in positive, healthy member behaviors
- Greater health equity
Staying in sync with multi-year trends like these can free you up to become more proactive and effective. And In today’s MA marketplace, that’s a very healthy thing.