One thing goes without saying: When it comes to quality measures, every health plan aims for a five-star rating—and for good reason. Eighty percent of Medicare members are enrolled in plans with four- or five-star quality ratings, up 76 percent from last year.
With data like this—and a significant amount of money on the table—it’s no surprise that payers are looking for ways to create successful Star Ratings programs. If that’s your goal, here’s what you can do to get started:
Star Ratings: What They Are and How They Impact Payers
Centers for Medicare and Medicaid Services (CMS) Star Ratings have a direct impact on health plan enrollment and reimbursement. Payers today are increasingly incentivized to improve their scores on performance measures, and many are enhancing their Star Ratings programs to do just that.
CMS Star Ratings assess quality based on 40 different performance measures, including clinical processes, outcomes, and appeals. After scoring, contracts are rated on a one- to five-star scale, helping potential enrollees compare plans based on quality performance.
Medicare plans with at least four stars receive bonus payments due to their high quality of care. In fact, research shows that an improvement from three stars to four stars can increase revenue by 13.4-17.6% percent for Medicare Advantage Part D (MAPD) plans.
5 Steps to Create a Successful Star Ratings Program
Are you looking to create a program that increases Star Ratings and improves clinical quality measures? Follow these steps to ensure it’s cost-efficient and effective:
- Determine Specific Goals for Your Program
First things first, you need to define clear goals and objectives for your Star Ratings program. Which metrics does your health plan need to improve, and how can you initiate changes to elevate your performance? Developing a comprehensive, data-driven strategy with specific goals will guide decision-making and increase the effectiveness of your Star Ratings program over time.
- Keep Current on Evolving Star Ratings
CMS regularly publishes updates to regulatory revisions for Star Ratings. To be successful, payers need to be aware of changes to quality rating calculations. For example, CMS altered quality measures for 2021 and 2022 due to concerns about accurate data collection amid the COVID-19 pandemic. Changes will likely come again, and knowing what they are and when they will go into effect is critical for health plans.
- Identify and Address Relevant Gaps in Care
Gaps in care—such as missed health screenings, lack of immunizations, and medication non-adherence—can dramatically impact a Medicare plan’s Star Ratings performance and health outcomes. Identifying and addressing gaps in care as part of your patient engagement program will have a significant impact on your plan’s Star Ratings, HEDIS scores, DIR contracts, CQMs, and QRS ratings.
- Use Smart Data to Personalize Interventions
To truly make the most of your Star Ratings program, consider using artificial intelligence (AI)—or the combination of smart data and technology—to optimize your patient interventions. Rather than taking a shot in the dark, AI allows payers to identify high-risk patients with medication-related gaps in care and prioritize outreach based on who is most likely to be influenced. From there, you can personalize interventions for greater impact, using AI to determine the best channel, messaging, and timing.
- Intervene to Influence Behavioral Change
With a better idea of how to best influence behavioral change for each individual, you can deliver personalized interventions based on the quality measures you would like to improve. For instance, if your plan’s goal is to improve Star Ratings for adherence measures such as Medication Adherence for Diabetes Medications, you will want to target diabetic patients who are at risk of medication non-adherence and most likely to be influenced to change their routine.
This is when smart data becomes incredibly beneficial, helping Medicare plans deliver targeted interventions that are cost-effective and efficient. With AI to guide strategic decision-making, payers like you can develop successful Star Ratings programs that boost quality performance, bring down costs to create more affordable plans, and improve individual health outcomes.
Schedule a demo to see how AllazoHealth’s AI Engine helps payers boost Star Ratings and other quality measures for better overall performance.
About the Author
Dr. Linda Schultz
Dr. Linda Schultz is a results-oriented Healthcare Pharmacy Executive who excels at leading transformational, top-notch, interdisciplinary healthcare teams to create and execute outcomes driven clinical operations and account management initiatives. Dynamic and knowledgeable in all healthcare business segments, most passionately within the complex Medicare, Duals and Medicaid markets, she is an accomplished, creative motivator and driver of innovative quality and cost of care pharmacy interventions. Dr. Schultz is currently VP, Customer Success at AllazoHealth, a cutting-edge, healthcare artificial intelligence company. Prior to her leadership role at Allazo, Linda founded and led RxHorizons, LLC., an international healthcare consulting group. Her expertise stems from over 25 years of experience within the Managed Care industry, with a focus on leading, strategizing, developing and implementing pharmacy benefit management activities within national PBMs and health plans.