It has become evident by changes to the Centers for Medicare & Medicaid Services (CMS) Star Rating formulas over the past several years—and especially with changes implemented for the 2021 Plan Year—that member experience and medication adherence is of utmost importance to the CMS. Health plans calculate Medicare Star Ratings measures primarily using Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data.
HEDIS consists of a standardized set of performance measures used to rate health plan performance with respect to health issues, including cancer, smoking, heart disease, diabetes and asthma.
CAHPS data comes from surveys that measure the patient or member experience as they interact with health plans and healthcare providers, such as doctors, nurses, and others in settings like hospitals, physician offices, and other healthcare facilities.
Health plans calculate the Star Rating for each Medicare Advantage (Part C) and Part D (Prescription Drug) Plan using the weighted average of various quality measures. This is a bit of an oversimplification of the process as there are 34 measurements for Part C plans and 14 measurements for Part D plans, and the calculations and data sets are quite complex.
As we mentioned earlier, CMS made several changes to how it calculates the 2021 Medicare Star Ratings. These changes give significantly more weight to the member experience measures. The following section provides a synopsis of the changes for 2021.
Medicare Star Ratings 2021 Changes
CMS increased the weight of patient experience measures, determined by CAHPS, member complaints, healthcare access, members choosing to leave the plan, appeals, and call center measures, all of which reflect overall member experience. The weight of these measures moved up from 1.5 to 2 for the 2021 Plan-year Star Ratings. Additionally, the CMS finalized its proposal to increase the weight of these member experience measures from 2 to 4, starting with the 2023 Plan Year Star Ratings.
Important Medicare Star Rating changes from plan-year 2020 to 2021
2020 | 2021 | |
---|---|---|
Changed | Part C and Part D improvement measures (C30 & D06) for MA-PD contracts Part D measure Drug Safety and Accuracy of Drug Pricing: D10, D11, D12, D13, &D14Comprised of 2018 HEDIS & 2019 CAHPS data | Member Experience and Access categories changing from 1.5x to 2.0x Statin Use in People with Diabetes Measure increased to 3Revised Plan Makes Timely Decisions about Appeals2022 Star Ratings will be comprised of 2020 HEDIS, 2020 HOS, and 2021 CAHPS data |
Transition of a Measure | Part C measure – Controlling Blood Pressure was temporarily moved to the display page for the 2020 and 2021 Star Ratings because NCQA made substantive changes to the measure specification | Part C measure – Plan All-Cause Readmissions was temporarily moved to the display page for the 2021 and 2022 Star Ratings because NCQA made substantive changes to the measure specification |
Retired Measures | Changes to the Plan All-Cause Readmissions measure will retire it from the 2021 and 2022 ratings | None |
Medicare Star Ratings 2021 Performance Overview
Due to changes in the CMS Star Ratings 2021 calculations and the impact of the COVID-19 pandemic, CMS calculated the 2021 Star Ratings differently than usual. It replaced 2021 Star Rating values based on HEDIS and CAHPS with values from the 2020 Star Ratings (care delivered in 2018). However, there was still an impact on overall Medicare Star Ratings from the previous year.
Out of 400 rated plans, 72 plans received a 4.5 Star rating in 2020; CMS reduced that number to 63 plans in 2021. The number of 5-star rated plans increased by 1 from 20 to 21 in 2021. The graphs below show the movement across all Star Ratings for Medicare Advantage and Part D plans from 2020 to 2021.
These changes in the Star Rating measures and weights emphasize the CMS’ continued focus on member experience, but in a way that has more significant financial impact through the Quality Bonus Payments (QBP), which is based on Star Ratings. Plans that excel in member experience will earn higher Medicare Star Ratings and a higher QBP, which translates into an increased rebate share. This allows those plans to maintain or increase the benefits provided to their members and mitigate increases in member premiums, all of which will position the plan for greater member growth and profitability.
How To Improve CMS Star Ratings
Member Experience, Complaints and Access Measures
The need for solutions to maximize member-experience measures will be greater than ever as we move forward, and the weight of those measures continues to increase. Star measures continually shift as CMS raises the bar. Inovaare solutions help health plan teams responsible for overall Medicare Star Ratings, as well as those focused on individual measures, implement the tools and systems they need to maximize Star Ratings. Medicare Stars expertise—combined with the systems and tools in place to support internal Stars teams—are essential for health plan growth and financial success, especially concerning the member experience measures listed below, which are more important than ever.
Part C Measures | Part D Measures |
---|---|
Getting Needed Care (CAHPS) | Call Center – Foreign Language Interpreter and TTY Availability |
Getting Appointments and Care Quickly (CAHPS) | Appeals Auto-Forward* |
Customer Service (CAHPS) | Appeals Upheld* |
Rating of Health Care Quality (CAHPS) | Rating of Drug Plan (CAHPS) |
Rating of Health Plan (CAHPS) | Getting Needed Prescription Drugs (CAHPS) |
Care Coordination (CAHPS) | Drug Plan Complaints* |
Complaints about the Health Plan* | |
Members Choosing to Leave the Plan | |
Plan Makes Timely Decisions about Appeals* | |
Reviewing Appeals Decisions* | |
Call Center – Foreign Language Interpreter and TTY Availability |
*Inovaare solutions are available to assist with improving this member experience measure.
Looking Ahead
Inovaare can help Medicare Advantage plans and providers deliver quality care and improve customer experience measures to increase Medicare Star Ratings, with a goal of achieving a 5-star rating, by implementing either our new A&G Pro 30 or A&G Enterprise solution. A&G Pro 30 provides an out-of-the-box solution that health plans can implement within 30 days to lower operating costs and improve the member experience. It also provides health plans with end-to-end visibility of real-time data for accurate monitoring, better decision making and expedited resolutions.
For health plans requiring high levels of customization, Inovaare implements A&G Enterprise. A&G professionals, with decades of leadership experience in health plan appeals and grievances departments, support A&G Enterprise, ensuring payers receive a tailored system that meets their unique needs. Industry consultants also help integrate best practices into the customized solution.
Inovaare provides highly configurable healthcare payer-specific software solutions that automate quality and compliance operations. We help organizations reduce risk, increase compliance visibility, lower operational costs and improve their oversight process.
FOR MORE INFORMATION, visit www.inovaare.com or call 408-850-2235
For additional information on the changes and updates to the 2021 Star Ratings system, https://www.cms.gov/files/document/2021starratingsfactsheet-10-13-2020.pdf
Overall Star Rating Distribution for MA-PD Contract https://www.cms.gov/files/document/2021starratingsfactsheet-10-13-2020.pdf
Weight of Patients’ Experience and Complaints Measures and Access Measures pg: 33892 https://www.govinfo.gov/content/pkg/FR-2020-06-02/pdf/2020-11342.pdf
Craig Giangregorio, A&G Industry Expert