Melissa Smith

The $64,000 Question in Star Ratings

Leave a comment | Share | |

As we wrap up the 2nd quarter, health plan leaders across the country are beginning to ask their Star Leaders the $64,000 question:  “Are we on track to achieve a 4-Star Rating this year?”

This is, perhaps, one of the most challenging questions that can be posed to any Star Leader at this point in the year. But with up to 5% of a health plan’s revenue driven by Star Ratings, the question is unavoidable, and the answer is vital.Though there is no simple answer to this question for a few more months, this is an opportune time to pause and reflect on 2015 Star Ratings progress against your plan’s strategic and tactical strategy to raise ratings.

It is often not easy for Star Leader’s to quickly describe the potential impact of the many changes we are awaiting in the 2016 Star Ratings: removal of the predetermined 4-Star thresholds, changes to the specifications for many measures, and removal and addition of yet more measures.  Because the window is closed for us to impact our 2016 Star Ratings, we now sit in the uneasy waiting period while the Centers for Medicare & Medicaid Services (CMS) finalizes the 2016 Star Ratings and measures. CMS is also finalizing the 2016 display measures and reaching preliminary conclusions as to which 2016 display measures may be included in the 2017 ratings. These potential new display measures are being impacted by the services we are delivering this year ‒ and in many cases, may not even be on the radar screen of our staff and provider networks.

So what can we do while we wait?

  • Evaluate your plan’s performance against national benchmarks to begin assessing your relative performance within the industry.  Use this information to help set expectations while we await the 2016 ratings.
  • Review your 2015 work plan, and current progress against the work plan, to ensure that your 2015 Star Ratings weaknesses are being adequately addressed and you will not repeat tactics that do not work in plan year 2016.  Objectively evaluate how effectively customer service, case management, disease management, and pharmacy teams are coordinating care and services for your members by evaluating measurable outcomes.
  • Review your quality program’s year-end evaluation, the Chronic Care Improvement Program (CCIP) and Quality Improvement Project (QIP) data to identify changes which may be required as new information is released by CMS, and consider proactive expansion of quality activities into the areas under consideration by CMS.
  • For Special Needs Plans (SNPs), review your Model of Care (MOC) evaluation for improved strategy opportunities related to the measures.

Educate and Activate.  There is plenty of time remaining to shore up operations and infrastructure to achieve Stars success.   As we continue to await release of the long-anticipated Medicaid managed care proposed rule, we are closely watching to see whether CMS will include value-based payments, new MOCs, and quality-based payment and oversight programs within yet another government health program.  These potentially transformational changes in the Medicaid quality management infrastructure, combined with the Quality Rating System (QRS) program currently being beta tested within the Marketplace, continue to reinforce CMS’ current and future emphasis on quality.

Our success in quality programs will require us to embrace CMS’ expanding vision for healthcare quality and translate that vision to empathetic, outcomes-focused engagement with patients who need, and will be responsive to, help from their care team.

By improving clinical quality performance, we can improve health outcomes and reduce the cost of care.  Find out how in our new White Paper now available..

Don’t know where to start? Contact me today at



Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let’s work together to help your plan achieve 4 Stars.

GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. Visit our website to learn more >>

Melissa Smith

About Melissa Smith

Melissa Smith is the Vice President of Stars at Gorman Health Group (GHG). She brings more than 20 years of healthcare experience to GHG, more than five of which have been in an operational leadership capacity in Medicare Advantage (MA) and Part D health plans.

Leave a Reply

Your email address will not be published. Required fields are marked *


You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>