Getting a Jump Start on Measures

Every January, we return from the holidays facing a Star Ratings conundrum. We must decide how much to invest in solidifying our 2018 Star Ratings while simultaneously looking into the Centers for Medicare & Medicaid Services (CMS) crystal ball to deciding what (and how much) to begin investing in our 2019 Star Ratings. We’re still reporting our 2016 performance (even without yet knowing exactly which measures CMS will include in the 2018 ratings) while we are developing 2017 dashboards to monitor our 2019 Star Ratings. And all of this while adjusting to benefit design changes, acclimating new members, and readying ourselves for the impending insights from the Advance Notice and Call Letter.

During these first few months of a new year, many plans take a brief break from conducting measure-focused activities in support of their Star Ratings program. One of the most common reasons we hear for this is plan staff doesn’t yet know which members will be in their clinical denominators this year – and there are so many other competing priorities that Star Ratings activities can wait a few months.

But maintaining momentum supports a sustainable, strong Star Rating. The first quarter of the year offers a unique opportunity for many member interventions that can serve as the foundation for a solid Star Ratings program for the remainder of the year. The value of these interventions can transcend Star Ratings and arguably should be done regardless of whether these measures are Star Ratings measures or not. For example:

  • Members who were non-compliant on the Healthcare Effectiveness Data and Information Set (HEDIS®) Diabetes Care – Blood Sugar Controlled measure last year due to lack of an A1c screening and who have re-enrolled with your plan may need help getting connected with the in-network care they need. Whether through transportation, appointment setting, or coaching, these members may just need a little extra help to take the next step. These members went a full year without a compliant screening last year, and there is no reason for us to think this will change on its own.
  • Members whose last A1c test in 2016 was >9 may need some support and follow-up to help them adjust impactful lifestyle choices such as diet, exercise, or adherence to their medications early in the year so such changes have adequate time to manifest in lower A1c levels before the end of 2017. It takes time for medication and lifestyle changes to impact A1c levels, and waiting until late in the year decreases our likelihood of success.
  • Members who were non-adherent during the prior year and who have re-reenrolled with your plan may experience any one (or more) of a variety of challenges that manifests itself in non-compliance on medication adherence Star Ratings measures. By working with such members early in the year to identify the cause of their non-adherence, effective support can be deployed at the right time, and through the right channel, during the remainder of the year to help improve that member’s adherence in 2017.
  • Rejected pharmacy claims present another member support opportunity. Whether rejected claims at the retail pharmacy occur due to benefit setup issues, transition issues, or formulary changes, these experiences often create visceral, long-remembered perceptions for your members which can influence their responses to both Part C and Part D Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey questions. Establishing a process to help ensure members experiencing a rejected claim successfully obtain (covered) medications, to reshape member perceptions of that experience, and to demonstrate how much you and your staff care about helping them get all the care and support they need can shape your CAHPS® survey responses.

Yes, it’s true we don’t yet have 2017 denominator information. But it’s also true activities such as these can simultaneously support our Star Ratings while also helping us think bigger than Star Ratings. By expediting our work with members into the early weeks and months of the calendar year, we’re improving our care coordination, supporting improved outcomes, and allowing ample time during the remainder of the year to follow up with our members in the right way at the right time. When we push these efforts later in the year, we may indeed be able to close certain Star Ratings measure gaps, but we must do so when the clock is ticking and in an environment where staff resources (and corporate priorities) often prevent effective, supportive follow-up with members.

With the many changes that lie ahead for us under the new administration, combined with our providers’ refocused priorities under the Medicare Access & CHIP Reauthorization Act (MACRA), our team of experts can help you develop or enhance your Star Ratings work plan, your provider engagement strategy, or your member engagement strategy. For questions or additional information about how Gorman Health Group can support your Star Ratings efforts, please contact me directly at



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Melissa Smith
Melissa Smith

Melissa Smith is Senior Vice President of Stars & Strategy at Gorman Health Group, LLC (GHG). Melissa’s team helps clients improve performance within quality ratings systems such as Star Ratings, improve health outcomes and the member experience, evaluate market dynamics and opportunities, optimize distribution channels, and supports our clients’ strategic planning needs.

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