What's In the Stars for Managed Care? Blog Feature
Joni Orand

By: Joni Orand on October 14th, 2020

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What's In the Stars for Managed Care?

Quality data | Quality and patient satisfaction | CMS Star Ratings

More than 22 million people are enrolled in The Centers for Medicare & Medicaid Services’ (CMS) Medicare Advantage (MA) program. Most choose a plan based on CMS’ five-star quality rating; after all, who doesn’t want the best care available?

But what CMS pares down into a simple rating based on the average beneficiary’s experience is a complex, changing constellation of elements. To succeed in providing high-quality, affordable, personalized service to patients, there’s only one way forward for managed care organizations (MCOs) and provider networks: Invest in a quality improvement strategy that includes technology showing you where to improve.

Star power 

The stars matter. Or more accurately, what they represent matters in the consumer-empowered health system CMS strives to achieve. Medicare members want to know about the experiences that other beneficiaries have had with their health plans, and how their own encounters measure up.

Early detection, wide access to care, and good customer service matter. Members want their health needs taken care of—and more

As a result, wide-ranging quality measures are presented as just one CMS rating on a scale of 1 to 5 stars, across these five categories, to help consumers compare health plans more easily:

  1. Staying healthy: Plans are rated on whether members had access to preventive services to keep them healthy. This includes physical exams, vaccinations, and preventative screenings.
  2. Chronic conditions management: Plans are rated for care coordination and how frequently members received services for long-term health conditions.
  3. Member experience: Plans are rated for overall satisfaction with the health plan, including access to care.
  4. Member complaints: Plans are rated on how frequently members submitted complaints or left the plan, whether members had issues getting needed services, and whether plan performance improved from one year to the next.
  5. Customer service: Plans are rated for quality of call center services (including TTY and interpreter services) and processing appeals and new enrollments in a timely manner.

The star ratings are generally based on measures of performance during a period that is two calendar years before the year for which the ratings are issued. Therefore, 2021 star ratings will be based on performance during 2019, and the 2022 star ratings will be based on performance in 2020.

COVID-19's effect on ratings

Because 2020 was an extraordinary year in which COVID-19 affected all facets of healthcare, the 2022 Star ratings (which include 2020 data) will still be calculated. However, CMS announced that plans will have greater flexibility in the data they submit to determine their scores and their subsequent quality payments.

Where the stars align 

Becoming a five-star plan is prestigious and brings valuable bragging rights. Earning at least four stars qualifies your plan for bonus payments—usually around 5% per member per month—which are returned to beneficiaries as enhanced benefits, reduced premiums or copays, or expanded coverage. Plans rated at either a three or three-and-a-half stars fall below the minimum requirements to qualify for bonus payments, and plans with fewer than three stars are subject to loss of their MA contract. 

Measures used to determine star ratings are essential for more than just great marketing around quality; they overlap with numerous other programs that affect network providers and health plans’ reimbursement, such as:

  • Quality incentive programs: One example of a QIP is CMS’ End-Stage Renal Disease Program, designed to promote high-quality services in renal dialysis facilities.
  • Healthcare Effectiveness Data and Information Set: HEDIS is a tool created and managed by the National Committee for Quality Insurance (NCQA) and used by health plans to measure performance on important dimensions of care and service. 
  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey or the Health Outcome Survey (HOS): CMS conducts these member satisfaction surveys anonymously to gather data about beneficiaries’ experience with providers. 
  • Physician Compare: This web site provides beneficiaries information related to providers’ quality performance, and uses many measures that overlap with the star benchmarks. 
  • Specific clinical initiatives: Other programs incentivize providers when patients stay current with tests, screenings, and other appropriate care (e.g., cancer screenings and bone mineral density tests).

Shine a light on improvement 

CMS rates health plans that include prescription drug coverage (PDC) on more than 40 unique quality and performance measures. Plans without PDC are matched against more than 30 quality measures.

All of these benchmarks undergo a review at least annually. CMS keeps, tosses, or adjusts them based on stakeholders’ feedback, data reliability (as data accumulates), and CMS-solicited clinical recommendations. 

As a result, it can be hard to know where to focus quality- and value-improvement efforts to maintain or improve your star rating. In concert with the guidance of your regulating body, your MCO’s secret to gaining star power should focus on the intersection of quality and provider performance monitoring, using web-based software to administer:

  • Incident/event reports
  • Complaints management
  • Survey administration
  • Idea improvement tracking
  • Peer review and provider performance measuring

Quality management software that’s part of a total provider data management solution levels the playing field for achieving higher ratings. Using web-based tools such as incident reports within a comprehensive provider management platform allows you to monitor and prioritize which measures are critical for improvement.

You can also track all instances of communication with members and providers, link incidents to ongoing peer review or focused professional practice evaluations, and conclude cases with rewards, commendations, and a map for providers of individualized quality-improvement areas.

Quality isn’t produced magically despite the best efforts of your staff and providers. It’s composed of multiple levers, most of which your MCO or provider network can control. Technology created for the intersection of quality, patient safety, and peer review can be your guide.

Let symplr help you reach for the stars with Quality Issue Manager



About Joni Orand

Joni Orand has worked in the healthcare industry for twenty eight years’, in both managed care and hospital environments, working with providers and staff gaining unparalleled experience in all aspects of provider management and quality improvement initiatives. She holds a degree in Corporate Communications, with minors in Interpersonal Communication and International Studies in Communications. Joni is a certified trainer, speaker and coach, and is known for helping, educating, and supporting clients as they develop quality improvement plans. Currently working as a Senior Solution Consultant for symplr, Joni speaks as a Subject Matter Expert at industry events.