How Medicare plans can improve their Star ratings

By: Wes Morris, Associate Director, Optum Clinical and Quality Solutions

The Five-Star Quality Rating System is an important part of the Centers for Medicare and Medicaid Services’ (CMS) goal to improve the quality of care and general health status for beneficiaries. For Medicare plans, the consequences of falling short of an overall 4-star rating can cost millions of dollars.

Here’s what’s at stake:

Yet over the past three years, the average ratings for Medicare Advantage, PDP and MA-PDP plans have decreased. We calculated the average rating for the improvement measures — more on these in a minute — based on the data available in the CMS master table for each year. We also looked at how many of the rated contracts received 4+ stars for the Part C and D summary ratings in each year. As this chart reveals, ratings are falling.

How can Medicare plans improve?

Before you consider how to elevate your score, it’s useful to understand how the measures are calculated. Plans often mistakenly believe the improved cumulative results of their Star programs’ performance will lift their overall improvement measures as well.

Such is not the case. To correctly predict the effect of improvement measures, you must focus on the subset of measures included in the calculation, and prioritize measures based on their weighting and plan performance. Health Plan Quality Improvement and Drug Plan Improvement have only one improvement measure each. Yet these measures carry the highest weight. And improving them can have a significant impact on a plan’s overall Star Rating.

We’ve identified a five-step process to boost improvement measures and overall ratings. It starts with reviewing prior-year measure rates. This helps clarify which measures are significantly improving and which are declining, which is critical to setting goals. Want to learn more? Read Five steps to maximize Star Rating improvement measure performance.


About the Author:

Wes Morris is a clinical and quality leader with more than 10 years of experience across multiple health care companies and quality functions.

Wes leads the Optum Stars Management Reporting Platform, which empowers health plans to make informed decisions regarding where the organization can affect the care, services and satisfaction being received by members in order to close quality gaps and achieve plan goals. He is responsible for leading overall product direction and client product delivery.

Prior to joining Optum, Wes served as a service and operations program manager in the Stars organization at Humana

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