3 Medicare Star Rating Roadblocks (and How to Address Them)

Published on October 14, 2019

The Centers for Medicare and Medicaid Services (CMS) applies Star Ratings to improve the competitiveness and quality of Medicare Advantage health plans. However, plans face major challenges in achieving better scores.

Most of these roadblocks are data related. 

In Carrot Health’s latest white paper, we describe how health plans can improve Medicare Star Ratings by addressing these roadblocks:

1. Understanding how well a plan meets the needs of beneficiaries.

Plans largely rely on administrative claims to track member compliance. It can be quite hard, however, for plans to track compliance measures that are biometric based. In addition, it’s difficult for plans to determine which members are satisfied with the service they receive from their clinical or pharmaceutical providers or to assess whether self-reported physical and mental health outcomes are improving for the overall member population. Accordingly, Medicare plans don’t always know which members should be targeted or prioritized for the kind of extra attention that might improve health or engagement and, ultimately, improve Star Ratings performance.

2. Achieving alignment with providers on member health objectives.

Health plans that are vertically integrated with most or all of their providers have more “control” over the services those providers offer. They also have ready access to electronic health records which can augment or inform their understanding of health outcomes and quality of care. Health plans that are not vertically integrated face a conundrum. While ultimately responsible for member health and experience, they rely on their network of providers to administer the tests and screenings, provide the service and deliver the results that will keep members satisfied and healthy. As such, those plans must figure out how to align and guide clinicians in ways that will help the plan meet its objectives for member service and health outcomes.

3. Calculating the ROI of member outreach.

Health plans must also figure out (ideally in real time) whether its outreach and engagement efforts with beneficiaries are effective from both a cost- and health- outcomes standpoint.

With data that’s current, relevant, granular and actionable, Medicare plans can operationalize sophisticated strategies in all three of these areas: member engagement, provider alignment and outreach ROI with the goal of boosting Star Ratings.

Our new white paper – “Leveraging Data to Boost Star Ratings Performance: Three Steps to Building and Operating an Exceptional Program” – details the characteristics of successful programs built on robust data collection and analysis. In addition, it outlines concrete steps plans can take to assess member and provider performance, enhance engagement and alignment, implement effective outreach/engagement strategies and drive improvements in organizational learning and program excellence year over year.

Not ready to download the paper? You can learn more about the action plan for boosting Star Rating performance in this recent blog post.

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