Peter Manoogian and Naoko Nishitani co-wrote this article with Shreya Raghuraman.
Since 2010, Medicare Advantage enrollment has grown 71%, according to a report by the Kaiser Family Foundation. As the eligible population continues to age-in, health plans have a tremendous opportunity to deliver quality care at more scalable costs than traditional fee-for-service Medicare.
The CMS Stars incentive program continues to be an area of focus for plans looking to drive top-line growth. CMS awards Medicare Advantage contracts an annual rating out of five stars, rewarding plans that earn four stars or above with a quality bonus. The program is intended to promote consumer transparency by evaluating a plan’s ability to manage health outcomes and member experience. In reality, the ratings are a high-stakes effort with millions of dollars at stake.
This year’s RISE Medicare Stars Master Class signaled a shift in how health plans are thinking about their 2019 activity. As the incentive program has matured, so has the strategy for how plans optimize their scores. As health plans adjust their efforts for the 2019 measurement year, here are our biggest takeaways from the Stars Master Class.
1. Stars competition will only get fiercer. The marketplace is becoming increasingly crowded while the stars program itself becomes more challenging. Six hundred new Medicare Advantage plans are launching in 2019, shifting power to the consumers who will have access to more than 10 plans, on average. Moreover, the average enrollment-weighted star rating for Medicare Advantage and prescription drug plans increased from roughly 3.2 to 4.1 between 2011 and 2018, indicating that plans are getting better at obtaining stars. Lastly, as plans become more effective at driving ratings, CMS continues to raise the bar. Outcomes measures such as medication adherence and screenings have seen an increase in cut points—the ranges required to achieve a rating—over the last few years.
2. Consumer experience scores will become more influential. Historic performance on CAHPS consumer experience measures has remained stagnant, fluctuating between 3.3 and 3.4 stars over the last few years. In response, CMS has made consumer experience scores more influential by increasing the weights of the member access and experience metrics from 1.5 to 2.0 in the overall calculation. As the 2019 measurement year begins, plans that invest in overall member experience instead of just the individual pieces may be better positioned to earn—and keep—higher ratings.
3. Understanding what’s in a plan’s control can be a powerful lever. Identifying what’s truly in a plan’s control can lead to unexpected solutions. One plan realized that its members had longer expectations for wait times because of cultural factors in the plan’s region, so instead of focusing on patient access, the plan reallocated efforts to more impactful measures for their members. Another plan discovered that its CAHPS scores were artificially low due to a disproportionate number of illiterate beneficiaries in their membership. They were able to account for this in their ratings, ensuring survey accuracy through improved understanding of their members.
4. Accountability needs to exist throughout the organization. Developing a high-functioning, quality program at a plan requires executive sponsorship, a long view, and cross-functional organizational commitment. To that end, some plans allocate responsibilities through a RACI matrix for each aspect of their program. This often extends well beyond the team that’s accountable for a plan’s overall score. Resources may be important, but similarly sized plans at the RISE conference with “stars teams” as small as one or two performed just as well as plans with robust teams of 10-plus members. Real change comes from collaborating across business functions, providers and care coordinators.
5. Data usage will be a key differentiator. There’s a disparity in how organizations leverage their internal and external data to drive behavioral change with members and providers. Each plan has a different model for how data informs their consumer experience, ranging from pathway analyses to qualitative decision journeys. Data usage that's linked to an overall stars strategy, using both quantitative and qualitative tools, is most effective at enabling plan improvement.
The bottom line is that there is no silver bullet that can substitute for strong program management, accountability and organizational buy-in. Plans that set up the foundational infrastructure for sustainable success will continue to be rewarded, not just through stars incentives but through a growing membership of satisfied, healthy consumers.