Three Strategies to Improve CMS Stars Rating and Earn a New Source of Innovation Funding

For years, every conversation we’ve had with clients about launching clinical innovation projects involved a common barrier to progress: money. But organizations are beginning to recognize that raising their Stars ratings beyond basic compliance can produce a new source of funding to help drive business transformation initiatives and innovative evolution.

A positive Stars rating, by virtue of its bonus payments and expanded access to new customers, is probably the most promising strategy to offset any loss of revenue and help secure additional capital towards business focused innovations. But improving your health plan’s performance to capture the bonuses won’t be easy.

There are three possible paths to follow to achieve higher Star ratings and grab that capital: collaboration, analytics and excellent execution on foundational capabilities.

1. Collaborate with members and providers

Breaking down silos to boost collaboration across functions and stakeholder communities is critical to improving Stars ratings.  Health plans should define a path of action mutually with members, patients, physicians, nurses and pharmacies to reduce the friction in operations and improve patient experience and outcomes. You’ll need multichannel interactions and insightful data aggregation to understand the member and provider experience more thoroughly, including social media listening to understand member sentiment and head off complaints before they result in lower scores on the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS). The goal of collaboration is to create a satisfying brand experience anchored by open communication with members and providers and promoting proactive, targeted preventive care efforts.

2. Integrate and analyze data from multiple sources to predict behavior and craft messages

Health plans have access to an enormous amount of data, but much of the insight available is simply overlooked, due to lack of appropriate analytics and a reactive approach. Improving performance and sustaining excellence is more than maximizing revenue through risk management and improving clinical metrics. To improve engagement, satisfaction, and long-lasting quality, you need a smart, data-driven approach using cutting-edge technologies like cognitive computing and machine learning. You also need a data set that goes beyond claims and EHR data to include data from social media and other outside resources that help you predict the social determinants of health for your members.

Most health plans analyze data periodically to identify revenue opportunities, gaps in care, and clinical risk, and member communication is initiated to address these issues.  Though this approach provides incremental improvement, this approach does not produce a sustained and long-lasting impact on revenue, quality, satisfaction, and retention because it lacks many key components necessary for success and sustainability

To be sustainable, your analytics program needs to prioritize your outreach, personalize communications using insights from a wider data set, and adjust the intensity and channel mix for greater effectiveness.

  • Member prioritization – With a limited budget, you simply cannot reach every single member with the same intensity.  Like it or not, some members are more important than others in terms of their impact to overall revenue, quality, and meeting strategic Star measure goals. Health plans must use advanced analytics to identify those members who can have the biggest impact (today, as well as in the near future) and work with them to make behavioral changes to affect their health outcomes.  It’s also important to predict health-seeking and health acquisition behaviors in members, and use that insight in prioritization. 
  • Member communication & engagement – Generalized communication is helpful, but messages personalized to the member’s needs and preferred channel, and timed to be most useful, will be more effective in producing the behavior changes that will improve adherence to treatment and thus outcomes. This personalization should consider why a member is predicted to behave in a certain way and messages should be crafted that speak to underlying motivations.  Analytics can help you have a data-driven understanding of past, present and future member behavior, allowing you to create a roadmap of how to influence behavior over time.
  • Intensity and channel mix – The intensity and channel selection should be based more on a data-driven understanding of channel preference and likelihood of success, and less on the proximity to the end of the measurement year and the number of open gaps.

3. Don’t overlook the basics

Look through the member value chain to be sure your resources are appropriately focused on care management, network management, and member services. Look for opportunities to improve performance, enhance quality, and control costs. This is the foundation of a high Stars rating, and sets the stage for all your other efforts.

Growth means increased risk as well as increased opportunity

The number of Medicare beneficiaries is expanding every year, as aging baby boomers swell the over-65 population. And more of those seniors are choosing Medicare Advantage plans, which now account for  31 percent of all Medicare beneficiaries, up from 22 percent in 2008.  In five states, the penetration rate exceeds 40 percent, and that trend is expected to continue.

With this growth, Star ratings become even more important. Plans that achieve a 4.5 or above rating on the Stars system receive increased reimbursement rates, and the more members in your plan, the greater the dollar amount. Also, seniors can enroll in a 5-Star program anytime in the year, not just during open enrollment.

But that increased opportunity also increases your financial risk and intensifies the need to focus your efforts on key cohorts. To excel on the CMS Star ratings, you need to help high-risk members improve outcomes, which requires a focused, sustainable effort.

A higher Star rating will ensure higher pay back, which in turn will provide you funds to drive business innovation towards gaining competitive advantage and better market positioning in the quickly changing healthcare landscape.

Suman De, MD, MHA is Principal Consultant & Healthcare Solutions Leader for NTT DATA.

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