2023 Will Be a Year of Methodological Change for Medicare Advantage

In the final weeks of 2022, the Centers for Medicare and Medicaid Services (CMS) released a significant amount of proposed regulation and data to support the sweeping changes for Medicare Advantage plans. Actions by CMS indicate times are truly changing—the way plans operated yesterday will not be the way they operate in the future. The path forward in the Star Ratings program, the prior authorization process, value-based care and how data is shared between patients, their health plan and their provider must evolve with the goal of safer, coordinated and equitable care.

CMS is certainly positioning Medicare Advantage Plans to think and act quickly for success, especially amidst Tukey outlier deletion model. Health plans should read and re-read the following CMS proposed rules that were just released to fully understand the ask by CMS, both the implicit and underlying.

1. Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, Medicare Parts A, B, C, and D Overpayment Provisions of the Affordable Care Act and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation Specification. Read the proposed rule.

2. Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children’s Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-facilitated Exchanges, Merit-based Incentive Payment System (MIPS) Eligible Clinicians, and Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program. Read the proposed rule.

CMS provides many nuggets of valuable information on how the current administration is positioning plans to change, how they view the change as essential to the state of the Medicare Advantage program and the economy.

Tip: The 2024- and 2025 Star Ratings, Medication Reconciliation Post-Discharge (MRP) measure will continue to be a standalone measure in addition to being part of the Transition of Care measure. You will want to include both in your dashboards and forecasting.

Read more about the high-impact proposed rules released in mid-December and five things your plan should be doing in preparation.

Tukey Outlier Deletion Simulations

CMS released the Part C and D Star Ratings Tukey Outlier Deletion Simulations. As we anticipated, it featured a wide range in cut points changes. CMS selected Tukey as a validated statistical model for outlier identification. The outliers are identified using a conservative 3x Tukey multiplier which means the Tukey outliers are truly way outside of the norm. CMS removes outliers before clustering with the mean resampling calculations.

If you have not downloaded the two years of Star Ratings data, do it immediately, update your Stars dashboards to review how your plan would have fared in Stars Year (SY) 2022 and SY2023 with Tukey applied. Furthermore, adjust your measurement year (MY) 2023 tactics to ensure you are reaching more people to close gaps, managing your internal health plan operations and oversight of vendors and providers with precision to meet your goals.

A few nuggets to share with your leadership on the impact of Tukey in SY2023 include:

• The most impacted cut points were at the 2- and 3-Star level.
• HEDIS measures have wide variation in cut points swings as outlined in the tables for two specific measures.

• Health Plan Operational Measure requires near perfect performance with 5-Star cut points ranging from 95-100 for:
  • Plan makes timely decisions about appeals
  • Reviewing appeals decisions
  • Call center – foreign language interpreter and teletypewriter (TTY) availability

Consumer Assessment of Healthcare Providers and Systems (CAHPS) is not included in Tukey so lean into member engagement strategies to maximize your math path to 4+ Stars. Do not lose focus of the importance of CAPHS in your overall Star Rating due to the reduced measure weights. Execution on CAHPS is still critical to Stars success and the ability to receive a quality bonus payment. Make sure your plan is focused on CAHPS all year long and deploying the right strategy at the right time of year. 

Don’t wait until the New Year to start updating your dashboards, workplans, policies, procedures and value-based care contracts! Get on the record with CMS on the proposed changes. Provide your feedback on how the proposed changes could potentially burden plans, members and providers, and hinder the ultimate goal of providing equitable, safe and person-centric care. The more they hear from plans on the anticipated challenges of the proposed rules, the more they will reconsider and reflect on the overall impact. Submit comment to CMS no later than February 13, 2023.

As always, Healthmine consultants are available to help Medicare Advantage plans develop their path forward as regulations change. Our team has been working in the Star Ratings program since its inception. Let’s work together to identify your biggest areas of opportunity to gain and maintain Stars. Reach out at Kimberly.Swanson@Healthmine.com.