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CMS Star Ratings leave you seeing stars? The ratings system explained:

Everyone is discussing CMS Star Ratings lately and for good reason: plans that don't earn stellar ratings (i.e. 4 or more stars) this year will take substantial payment hits in 2015. As health plans continue to adjust to this new reality, there remains some confusion about the basic what, how and why of the Stars system. Here, we’ve broken down what Star ratings are, how they work, and why Medicare Advantage plans should be paying attention to them.

WHAT

Medicare Advantage plans are graded on a 1 to 5 “star” rating by the Centers for Medicare & Medicare Services (CMS) based on a range of quality metrics, including HEDIS® measures (HealthcareEffectiveness Data and Information Set). CMS originally developed MA Star Ratings as a system to help consumers compare quality among competing Medicare Advantage plans. Under the reforms brought in with the Affordable Care Act the government will now use these star ratings as a financial incentive to reward high quality plans with bonuses and rebates.  

HOW

The Stars system currently consists of 53 measures that are weighted 1, 1.5 or 3. These measures come from a variety of data sources, including standard HEDIS, CAHPS, and MHOS measures, CMS data, and independent CMS auditors. CMS performs a variety of statistical tests to translate these raw measures into stars ratings. The weighted average of these measures becomes the overall star score, which determines the quality bonus payment. 

An additional element of the star rating equation is the “i-Factor”, which is a boost in rating for a high overall average and low variance among measure scores. Highest rated plans depend on this boost to achieve their 4.5 or 5 overall score. However, the i-Factor is a bit of a wildcard as the cut points that determine who receives a bonus are recalculated each year so it is impossible to know for sure which plans will receive a bonus.

WHY

The Affordable Care Act has transformed the star rating system into a critical component of Medicare Advantage reimbursement. Currently, plans are eligible for bonus payments if they receive a rating of 3 stars or more. The higher the star rating, the more plans will receive in revenue from the government. There are also very real consequences for low performing plans: those rated with fewer than 3 stars consistently over the prior three years are flagged as low-quality on the Medicare website.  Additionally, CMS will terminate contracts that are consistently low performing.

The star rating systems continues to change and evolve. In 2015, only 4 and 5 star plans will receive quality bonus payments based on this year’s ratings, so with a 3 year lag between activity and payment, this means that 3.5 star plans that do not improve in 2012 will take substantial payment hits in 2015. CMS has also announced plans to add additional measures and redistribute the weighting of current measures in the coming years.  The guiding principles that CMS uses to evolve its stars and quality programs are to improve the individual experience of care and the health of populations.  CMS clearly sees health plans as accountable for the care provided by physicians and hospitals to their enrollees.

While the novelty of the star ratings system can still be a cause of uncertainty and anxiety for many health plans, it also represents an exciting opportunity for them to receive tangible credit for the quality they provide to consumers. “Quality has never had such a direct ROI before,” says our in-house stars expert Nancy Martin.  Because of the broad range of Stars measures, an effective stars strategy needs to include not only barrier busting interventions, but also programs that increase member  engagement, and most importantly programs that are delivered at the point of care through increased provider integration.

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