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How Are You Preparing for the 2018 Star Rating Changes?

The Centers for Medicare and Medicaid Services’ (CMS) Star Rating system has a major impact on a Medicare Advantage (MA) plan’s quality of care — and its bottom line.

CMS rewards MA plans that earn four or more stars with performance bonuses. These bonuses bring in an extra five percent a year per member. A four-star plan with half a million members, for example, would receive $250 million in bonus revenue — a significant incentive to improve plan performance.

It can be challenging, however, for MA plans to raise their Star Rating, or maintain their high one.

Low-performing plans can easily become stuck in a vicious cycle when funds are scarce due to substandard performance in previous years and a lack of reimbursement resulting from that subpar performance.

High-performing plans may have more funding to support quality initiatives yet lack the resources needed to implement truly meaningful activities that keep performance at a four- or five-star level, which is critical for retaining the five-percent bonus.

“Strategically addressing and investing in the measures that directly impact an MA plan’s Star Rating is crucial to its success,” says Jennie Echols, PhD, MSN, RN, Director of Clinical Solution Development, Carenet Healthcare Services. “Payers need to be preparing now for both the 2018 Star Rating and HEDIS measure changes, including developing the year-round engagement and activation strategies needed to elevate performance, realize bonuses and attract new members.”

2018 Star Rating Changes
For 2018, CMS added two new measures, including:

  • Improving Bladder Control (HEDIS/HOS data specifications)
  • Medication Reconciliation Post-Discharge (HEDIS data specifications)

One measure was retired:

  • High-Risk Medications (Prescription Drug Event data)

New HEDIS Measures Impacting Medicare Plans
While there are additional HEDIS measures for Medicare plans, these new measures are not yet included as Star measures. However, they still require attention for NCQA-accredited plans serving the Medicare population.

  1. Transitions of Care: Assesses the percentage of inpatient (IP) discharges for Medicare members who had each of the following during the measurement year:
  • Notification of IP Admission
  • Receipt of Discharge Information
  • Patient Engagement After IP Discharge
  • Medication Reconciliation Post-Discharge
  1. Follow-up After Emergency Department (ED) Visit for Medicare Members with High-Risk Multiple Chronic Conditions (Follow-up care within seven days of ED visit)
  2. Use of Opioids at High Dosage: Assesses rate of all health plan members who receive long-term opioids at high dosage
  3. Use of Opioids from Multiple Providers: Rate of all health plan members who receive opioids from multiple prescribers and multiple pharmacies
  4. Depression Screening and Follow-Up (if screened positive) for Adolescents and Adults
  5. Unhealthy Alcohol Use Screening and Follow-Up within two months (if screened positive)
  6. Pneumococcal Vaccination Coverage for Older Adults

Get the Experience and Results You Need
“Improving Star Rating and HEDIS measure performance is less challenging when you partner with an organization that has in-depth experience and proven results in these areas,” advises Echols.

Carenet has helped many MA plans develop and execute strategic initiatives that have resulted in member activation rates exceeding 65 percent for HEDIS measures. For example:

  • Annual wellness/primary care physician (PCP) visit: 79.75%
  • Colorectal cancer screening: 66.83%
  • Diabetes HcA1c screening: 88.59%
  • Diabetes eye exam: 66.84%
  • Diabetes medical attention for nephropathy: 82.02%
  • Osteoporosis management: 90.52%

“Plans with a lower Star Rating should be encouraged by the fact that many payers have increased their rating over the past few years demonstrating that, with the right resources, it can be done,” says Echols.

To learn how Carenet’s Strategic Engagement solution helped one of the country’s most prominent MA plans close more than 25,000 gaps in care and boost its Star Rating, click here.

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