How Do You Cross a Threshold to Success When There Isn’t One?

Many plans are reacting to the changes affecting the Star Ratings as described by the most recent release of the 2016 Advanced Notice.  One of the most impactful changes is that of the removal of the thresholds for plan year 2016 measures.  CMS gave early warning of the removal of the thresholds for many of the measures and restates their position as per page 86 of the Call Letter:

“Our primary goal in eliminating the thresholds is to improve the accuracy of the assignment of overall and Part C and D summary Star Ratings and to make certain the system creates incentives for quality improvement. While there is general support for this change, some sponsors and stakeholders remain concerned that it is difficult to improve without published targets for achieving 4 or more stars on a measure. We also understand that some sponsors are concerned that eliminating pre-determined 4-star thresholds will make it more difficult to set targets for performance or value-based contracting.”

It will be difficult for many plans to manage the removal of the thresholds when that has been the reliance for the benchmark of improvement in many instances — from improvement in the quality work plan (which, by the way, don’t forget, will have to be modified) to the provider incentive plan to the overall strategy for value-based contracting many plans are now trying to implement.

Because CMS stated that having pre-determined thresholds may restrict continued quality improvement, plans now must begin to become stronger in the quality improvement/assurance arena.  What does this mean for you? This means rethinking your quality work plan, the benchmarks or baselines used, and asking yourself as a plan: What other data sources can we now use to make sure we are on the road to continuous quality improvement?  This also means re-evaluating your Stars work plan/strategy and the tools used to support it.  How can you create a better dashboard for 2016?  Think about using industry standards already out there for the new “thresholds” and incorporate those into the dashboard.  In fact, why not try that exercise now — start running “new” thresholds” alongside the ones in place today for 2015 and see where your plan will land.   CMS believes this change of threshold removal will not impact the industry greatly.  In fact, they cited that their research shows close to 7% of plans would possibly have their ratings raised one-half a percentage point, and approximately 10% would go down by the same rate.  If plans want to be certain this really is the outcome, it is time to start preparing now, especially if your plan will experience a reduction to a greater percentage.

So what are good baseline or benchmark replacements, you ask? Well, let’s start with the easy one — HEDIS.  NCQA publishes a memo which reports the national benchmarks and national and regional thresholds for HEDIS/CAHPS.  Plans could start comparing themselves in this fashion now and preparing for the removal of thresholds, strategizing on the results they see.

Another thought: plans certainly have the capability to trend historically on their own performance — examine those 19 measures that have no threshold today and think about the interventions or methods used in the management of these.  Don’t be afraid to use the document published by CMS,  “Trends in Part C & D Star Rating Measure Cut Points,” and conduct the same exercise within your organization if you have not already. That document can be found here.

Also, have the discussion within your plan’s provider networking/contracting area and ask the question, “What does the threshold removal do to our contracting strategy and the use or identification of high performing providers?” Will we, as a plan, need to redefine what high performance means so we can measure it correctly? Will we, as a plan, need to change what measures/benchmarks on which we are paying bonuses? I think you will.

Plan to start tying providers to measures they can influence and then talk with those providers about changing outcomes for measured improvement.  Remember, you will have to help them prioritize now.

Plan and be prepared for the changes by reviewing your quality program, the QIPs you have in place, and how will they need to be modified to account for the changes coming down the road.

With a few simple steps, you can still cross over to success, even without a threshold!


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Jane Scott
Jane Scott

Jane Scott is Senior Vice President of Population Health Management and Clinical Innovations at Gorman Health Group (GHG). In this role, she is responsible for leading GHG’s Clinical Innovations practice area. Jane brings GHG clients 37 years of experience in healthcare as one of the industry leaders on the topics of the Centers for Medicare & Medicaid Services (CMS) Special Needs Plans (SNPs), development and implementation of Models of Care (MOCs), as well as the Star Ratings Quality Bonus Payment Program. Her experience expands to the areas of quality improvement (QI), utilization and medical management, claims operations, and provider/associate education.

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