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HMA Analysis of Medicare Advantage Star Rating Challenges

This week, our In Focus section highlights changes that may affect the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Star Rating program and how these changes impact future summary Part C & D Star Rating scores. As the CMS Medicare Advantage Star Rating program continues evolving from year to year, many plans have yet to achieve at least four star status, and therefore are missing out on additional Medicare revenues. The Star Rating landscape is expected to change drastically over the next two years for plans due to CMS’ continued focus on phasing-in greater reliance on outcomes measures and measures of care experience, rather than process measures. As a result, many plans are at risk of losing their four star overall rating and underperforming plans could be at risk of receiving a low performance indicator. 

HMA conducted an analysis of the potential impacts of the upcoming changes in Star Ratings. Roughly one-third of a MA plan’s overall score will be based upon member experience/survey based measures captured in the Consumer Assessment of Healthcare Providers and Systems (CAHPS). The HMA analysis finds that member experience appears to be the area that most health plans struggle to meaningfully impact and improve over time.  Given the weighting of these metrics, this means that some plans would be mathematically eliminated from hitting a four star weighting without significant changes to their CAHPS scores in 2023. An HMA review of MA plan performance showed that 126 Medicare Advantage Health Plans, which represent about 4.2 million members, have the potential to be negatively impacted by these CAHPS rating changes.  Of those 126 plans, HMA assesses that 57 are at significant risk and have limited viable pathways towards hitting a four star score or are at risk of becoming a low performing plan. These plans currently have almost 1.3 million members.

With so much changing in this space it is critical to keep an eye on three major items that have the potential to significantly disrupt the Medicare Stars performance landscape:      

  1. Increased weight of CAHPS measures: One of the material technical changes with impact to 2023 Star Rating is the increase of the  patient experience, complaints, and access measures from double to quadruple weighting. The measures affected by this increased weight are all part of the experience of care measures collected through the CAHPS survey. The increase in weighted value will impact the calculation of overall and summary Star Ratings and will not change the Star calculation at the individual measure level. This change in scoring methodology means that member experience will change from a weight of one-fifth to over one-third of the overall Star Rating score. Plans will have to place greater emphasis on listening and responding to beneficiary needs to succeed.
  2. Increased importance of pharmacy related measures: CMS makes changes from time to time in the measures that make up the Star Rating program. For example, the Plan All-Cause Readmissions (PCR) measure was removed from rating calculations for two years and it will come back in the 2022 measurement year for the 2024 Star Rating. In the future, CMS will temporarily remove two Health Outcomes Survey (HOS) measures due to measurement changes. This is important to note because as measures shift, the weighting of the remaining measures will change, which can have a significant impact on whether plans can improve or maintain their Star Rating. As a result of the most recent measure shifts, pharmacy measures will now have a higher impact on plans’ summary scores. Additionally, HMA is seeing pharmacy influenced measures become even more important in the Part C domain such as statin use.
  3. Likely increase in global cut points due to changes in outlier methodology: To increase the reliability and predictability of the point that the star measures change on the five point scale from say three to 3.5 (cut points), CMS is modifying how it identifies the cut points for non-CAHPS star measures. Cut points are the ranges from which the Star Ratings are calculated. CMS has indicated that it plans to use the “Tukey outlier methodology” to remove outlier data from the calculation methodology. This change in methodology is likely going to cause global shifts in the cut points on both the higher and lower ends next year. As there have been more lower scoring plans, HMA anticipates the result will be to raise the cut points. Plans must adopt a data driven, calculated, and purposeful approach to its non-CAHPS based metrics that qualify for these cut-point methodological shifts.

For the past several years, health plans looking to increase their CMS Star Ratings generally focused on metrics that they assessed as most impactable by a health plan, which generally included HEDIS, operations, and pharmacy-based measures.  However, reliance on cut points to move measurement scores and strategies that favor lower weighted measures will no longer have the same effect in improving Star Ratings. Instead, plans should consider implementing a multi-year CAHPS strategy that enhances member experience and access. If the Medicare Advantage plan outsources pharmacy services to a PBM, now is the time to discuss quality improvement goals and be more intentional about the pharmacy-related measures. Plans that have consistently demonstrated high performance generally have a data-driven approach to strategically address and resolve barriers to care that lead to poor measure performance, including social determinants of health (SDOH) and access to providers and pharmacies, in order to realize year over year CAHPS performance improvement.

HMA’s Medicare and Quality practices have deep experience with the development and implementation of best practices to improve and maintain a strong quality improvement model and culture within organizations. Specifically, we have been working with clients to develop customized CAHPS roadmaps to improve Star Rating performance and helping plans achieve economies of scale around maximizing their year-round Medicare stars strategy. For information on our Medicare and quality best practices, please contact Anthony Davis, Mary Hsieh, and Sarah Owens.