It’s no secret that the COVID-19 pandemic has impacted just about every facet of our lives—and the way we measure quality performance is no exception. In fact, the Centers for Medicare & Medicaid Services (CMS) changed the Star Ratings measurement system in response to the global health crisis.
Find out what payers need to know about the impact of COVID-19 on CMS Star Ratings:
Key Changes to CMS Star Ratings Due to COVID-19
The rise of the COVID-19 pandemic prompted CMS to change the rules regarding the calculation of Star Ratings. In April 2020, CMS issued a rule modifying data submission requirements for 2021 Star Ratings to address disruptions due to COVID-19.
Out of concern that the pandemic would impact the collection of Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and Health Outcomes Survey (HOS) data used to calculate the 2021 and 2022 Star Ratings, data calculations were modified for 2021 and 2022 Part C and D Star Ratings. CMS replaced the 2021 Star Ratings measures based on HEDIS and Medicare CAHPS survey data with earlier values from the 2020 Star Ratings.
Other 2021 measures with pandemic-related data quality issues were replaced with equivalent Star Ratings and scores from 2020. Plans were allowed to count data from either 2021 or 2022 Star Ratings—whichever was better—to boost performance.
CMS is also implementing several changes for 2023 and 2024 Star Ratings, including:
- COVID-19 corrections: COVID-19 corrections will likely result in a return to past performance, meaning a loss of many four- and five-star plans.
- Member experience: CAHPS member experience measures are rising to a rate of four for the 2023 Star Ratings, making up more than half the overall weight.
- HOS measure removal: CMS removed certain triple-weighted measures from calculations for three years to boost ratings. These will return in 2026.
- Controlling blood pressure (CBP): The CBP measure will return in 2023 and become triple-weighted in 2024 to increase its impact on quality scores.
- Care transition adjustments: The 2024 Star Ratings will incorporate measures for readmissions, transitions of care, and emergency department follow-ups.
What Are the Results of Star Rating Adjustments?
Regulatory changes during the pandemic have already resulted in a record number of Medicare plans receiving historically high scores, with a record number of Medicare Advantage Part D plans moving into the four- and five-star categories. In fact, nearly 70 percent of Medicare Advantage plans with prescription drug coverage will have a four- or five-star rating in 2022, a substantial increase from 49 percent in 2021.
As a result of these modifications to CMS Star Ratings, many Medicare plans can expect an unusually large payout in 2023—the highest payment in the program’s history. However, nothing is permanent, and payers need to prepare for upcoming COVID-19 corrections and future adjustments. Medicare plans looking to maintain their high CMS Star Ratings will need to adapt their quality improvement programs for what’s to come—but what does that mean from a strategic perspective?
Optimizing Quality Performance with AI Technology
Health plans can improve patient adherence and other quality measures by optimizing their efforts with artificial intelligence (AI). Technology like AllazoHealth’s AI Engine can improve the effectiveness of patient support programs focused on quality ratings and greatly impact CMS Star Ratings, HEDIS scores, direct and indirect remuneration (DIR) contracts, and Quality Rating System (QRS) ratings.
But how? It’s simple: AI improves intervention results and quality outcomes by targeting high-risk patients who are most likely to be influenced by an intervention, and then optimizing the channel, messaging, and timing for each individual.
Payers like Blue Cross Blue Shield of North Carolina have partnered with AllazoHealth, using AI technology to improve the effectiveness of adherence interventions. As a result, the regional payer generated a 5.5 times uplift in medication adherence and a 23 percent reduction in intervention spend compared to traditional, rules-based interventions.
If you’re looking for ways to maximize your health plan’s CMS Star Ratings both now and in the future, AI is the answer. Schedule a live demo to see AllazoHealth’s AI Engine in action.
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.