ARTICLE
The Centers for Medicare & Medicaid Services (CMS) 2023 Medicare Advantage Star Ratings are official. The end of pandemic-era COVID-19 relief, combined with decreased performance across most measures, caused pervasive erosion in performance data and ratings. With more than 25% of plans experiencing a decrease in their overall rating, there is much to know and be done as quickly as possible.
The member experiences measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) now comprise about one-third of the overall Star Rating, and we had a variety of measure additions, removals and changes. Let’s uncover takeaways from the 2023 ratings.
Star Ratings will be used to approve or deny expansion applications.
CMS’ new Past Performance criteria prohibits applicants from entering into new contracts and from service area expansions if any contract held by the organization has below a 3-Star Part C Summary, Part D Summary or overall rating during each of the last two ratings cycles. This new rule takes effect in spring 2023 for New Contract and Service Area Expansion Applications, effective January 1, 2024. The provisions are applied at the Legal Entity level, rather than the Contract or Parent Org level.
Because the 2022 Star Ratings were so strong, this new criteria will only block 2024 plan expansions in 13 contracts despite the rough 2023 Star Ratings. However, more than 10% of Medicare Advantage (MA) contracts earned more than 3 stars summary or overall rating for the first time. An additional 5% of MA contracts were impacted through common ownership by the legal entities that hold these at-risk contracts.
There are about 80 days left in 2022 to impact clinical care delivery for the 135 contracts whose 2025 growth and expansion plans are now at risk due to Stars performance. For these plans, the clock is ticking and there are no days, or even hours, to waste. Work should begin aggressively, immediately, and around the clock to preserve long-term strategic growth.
Improvement (or lack thereof) mathematically matters.
Although performance decreased on almost 70% of measures, the use of clustering and relative distribution largely masked the declines via eased cutpoints, which the industry celebrated during Plan Preview 2. But the decline in actual performance significantly impacted the heavily-weighted Improvement measures:
Improvement measures are designed to force plans to continuously improve through the private sector innovation and creativity that CMS leverages in MA. These two often-overlooked measures have a significant mathematical impact on summary and overall ratings. Many plans were negatively impacted by this in overall ratings and, perhaps even more importantly, the Past Performance criteria required to ensure corporate growth opportunities:
Not enough plans track, compute, manage, and monitor the Improvement measures. With 10% of the overall rating driven by these measures, and even more of the Part D Summary rating impacted by them, it is vital to tackle this math.
Precision, Creativity, Innovation and Expertise Matters.
When CMS codified Star Ratings in 2018, they did so with the express intent of more clearly and predictably announcing the program rules and measures ahead of the measurement period to allow enough time to plan multi-year initiatives. The flurry of stop, start, and pause amidst the sweeping clinical impacts of the pandemic made change harder and slower than normal for plans to execute. This is making it more difficult for plans as we embrace the first-ever addition of three new measures at once.
While CMS is expanding and accelerating its use of Star Ratings as a catalyst for meaningful change, many plans are struggling to locate staff knowledgeable enough to ensure success, struggling to find vendors whose services are aligned enough with Star Ratings needs, and to align new leaders around the new needs of Stars. This year’s struggling ratings remind us of the importance of measure and technical precision in every element of reporting, measurement, intervention design, operational alignment, and strategy so that investments can be relied upon for success. Directional improvements are not enough.
CMS’ return to the pre-pandemic normal approach to measure additions, removals and program changes is expressly intended to reward plans who innovate. CMS has modernized the Star Ratings program in ways that allow plans to strengthen benefits for and empower enrollees while encouraging innovation, flexibility and choice in ways that drive continuous improvement. We are now in the true test period of innovation, creativity, and entrepreneurialism. There are numerous changes already codified or proposed that take effect beginning in 2023.
This is a critical moment. Now is the ideal time to ensure every member of your team understands the need to stop chasing the past best practices of others, embrace your unique corporate strategy and company mission, and move forward boldly.
Here are a few things you can begin immediately to ensure your success:
1. Make sure your fourth quarter strategies are mathematically adequate.
Stars success is as much a math problem as it is a quality improvement activity. It is vital to always know the status of every measure, with member and provider detail, not only to achieve 4+ Star Ratings but also to ensure no summary or overall rating slips under 3 stars and triggers Past Performance criteria. This requires careful dashboarding, supplemented with member and provider measure data across all measure sets, ideally augmented with risk assessment response data to design and deploy the right interventions to the right members and providers in the right way.
Plans need to simultaneously monitor and manage every element of the improvement measure computations, summary ratings, and Reward Factor. Some plans have already lost too much ground on time-constrained measures and now must over-achieve on others to compensate. It’s not enough to pick a few heavily weighted measures, chase the best practices others are willing to share, and hope for the best. Know your high-priority members and providers by name, and by their needs. Make sure you are calling, texting, and engaging with enough of the right members. For members with gaps in multiple domains, make sure you are escalating their engagement to an appropriate level. This could mean implementing calls instead of texts for members with extensive needs or working with field personnel to engage members who are unreachable by phone.
This is also the month to add Tukey projections to your 2022 cutpoints and dashboards. We now have reasonable statistical models to give us a sense of which cutpoints will be changing this year when CMS removes outliers. Many cutpoints will change dramatically. If you do not have Tukey computations in place yet, this is the time to perform the math or purchase from a vendor.
2. Make sure you are ready for 2023.
Many plans realized this year that they do not have the right assets and levers in place to sustain Stars success. Most leaders are willing to resource fast fixes in the fourth quarter, and this is the ideal time to ensure 2023 budgets are complete. Ask yourself:
- Is your reporting package and process adequate for every mathematical element of MY2022/MY2023 Star Ratings?
- Is your reporting package and process adequate to support COL during its electronic clinical data system (ECDS) transition in 2023 and 2024? To support time-boxed measures all-the-time? To support the potential math CMS will use in 2023 to add health equity to Stars?
- Do all managers and leaders understand the imminent program and measure changes? Is it the time for monthly leadership realignment initiatives in 2023?
- Is your 2024 bid planning working the precise mathematical needs so that benefit enhancements organically improve both Stars and medical loss ratios?
- Is your capture of race, ethnicity, and language (REL) data adequate? Are you performing Health Risk Assessments (HRA) with enough, and the right, members? Are you digitizing all HRA responses and REL data in the data warehouse used for Stars reporting and analytics?
- Are your 2023 member and provider engagement tactics ready to capture all historical charts for colorectal cancer screenings to aid the measure’s 2024 conversion to ECDS?
- Are whole-person member engagement activities and tools in place to begin building the scaled, continuous relationship needed to handle Part D pricing changes and ensure Health Outcomes Survey measure success once the measures take effect on January 1, 2024?
3. Design and Plan Multi-Year Initiatives
CMS knows changes require time, and we have multiple high-impact, high-effort, high-stakes changes looming: the integration of health equity into Stars, the conversion of HEDIS to ECDS, the return of triple-weighted Health Outcomes Survey measures to Stars in 2024, and more. Plans who have not yet started planning and investing in these areas are behind the curve. Establish a clear plan, secure leadership buy-in and funding, and get started as quickly as possible.
If you have a contract at risk, there is plenty of time to get HEDIS Appointment Scheduling and Medication Adherence calls flowing in time to impact measure rates. There is even more time to get CAHPS Pulse Surveys deployed with members with enough time to intervene with members self-reporting negative proxy responses. We encourage our clients to design fourth quarter initiatives to include pathways to get members into a doctor to build the doctor-patient relationship that must exist for every member.
If you need assistance, we can help. From helping identify ways to improve your performance and developing a plan for improvement to augmenting your team’s Stars capacity, and even organizing scalable, efficient member interventions, our experts have deep expertise and can help. For more information, email me at melissa.smith@healthmine.com.