Becoming a Star at Star Ratings | Part 1: The New Rules of the Game
It’s a hard truth.
Despite many advances in care navigation, getting the right care at the right time in the right place is still a difficult challenge for most Medicare patients. The tasks they face are many, and the process is complicated—from scheduling an appointment that fits their busy schedules to determining the next best care action, serving as their own care coordinator, calling other service providers, such as pharmacies, and then arranging for follow-up care.
To address this issue, CMS has placed greater weight on its patient experience measures, used to determine Star Ratings, to better align accountability (read: reimbursement) for MA Plans and the PIPs for care entities.
The New Rules of the Game
As a result, making care services more accessible, convenient, and easy to navigate is no longer a consumer nicety; it’s a business necessity. Poor performers must determine how to improve performance (read: profitability). Top-tier plans must continue to find ways to stay ahead of the pack. Providers and medical practices who have primarily emphasized clinical benchmarks (read: HEDIS and others) and gap closures to maximize their financial outlook are having to evolve their thinking. Maximizing financial returns for a medical group now entails comprehending Star Ratings, MCAHPS, and CG-CAHPS performance metrics. In addition, merely excelling in performance with one health plan does not guarantee similar success with another, given that various plans cater to distinct demographics.
Where Medicare Goes, Others Will Follow…
It’s also important to note that Medicare is not the sole insurance provider focusing on patient experience measures. Medicaid and commercial plans also acknowledge that the consumer and member/patient experience play a pivotal role in member growth and retention. Medical practices also need to take notice. By approaching care coordination as a collaborative effort with health plans, medical practices can not only expand their reach and earn quality bonus incentives, they can also enhance the quality of care provided to their patients.
The Stakes Are High
According to the Advisory Board, when an MA plan increases its Star Rating from 3.5 to 4.0, it becomes eligible for additional bonus payments of $400 per member. For a plan with 100,000 members, that’s an additional $40 million in revenue.
Achieving higher Star Ratings can also lead to increased enrollment and member retention, translating into greater financial stability and growth. Conversely, lower ratings can result in reduced revenue, as potential members may be deterred by subpar ratings, and incentive payments may be diminished. Moreover, the CMS's ongoing efforts to tie reimbursement to Star Ratings further accentuate the financial stakes, as plans and providers must strive to enhance patient experiences, care quality, and health outcomes to maximize their financial success in an increasingly competitive healthcare landscape.
With so much at stake, it’s time for Medicare Advantage plans to take action. In the second of this two-part blog series, we’ll examine how health plans can maximize their investment to improve the member experience and enhance their Star Rating.
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