Influencing Your 2019 Star Ratings: Every Day Matters

With the recent release by the Centers for Medicare & Medicaid Services (CMS) of 2018 Star Ratings to health plans, the now-annual “4th quarter Star Ratings fire drill” is officially underway.  Whether you dropped below the 4-star threshold required to earn quality bonus payments, or you hit 4 stars and are hoping to sustain it, the next six weeks are critical to your success. But with only about 90 days remaining to connect members with the care they need for your success, every day and every decision matters.

The 2018 ratings offer a stark reminder that earning 4 stars is never easy. For example, among other things, we see:

  • Dramatic cutpoint changes: With few large swings in measure cutpoints the past few years despite the absence of predetermined measure cutpoints, many have developed prediction methodologies that assume relative stability in the cutpoints from year to year. However, the 2018 ratings include significant increases on all cutpoints for the Breast Cancer Screening and Controlling Blood Pressure measures, reminding us of the need to relentlessly pursue improvement, even when year-over-year comparisons look promising.
  • Measuring nuances: Consumer Assessment of Healthcare Providers and Systems (CAHPS®) measures represent approximately 20% of the 2018 Star Ratings measures, all of which are 1.5x-weighted. As the range between the 1- and 5-star cutpoints on these measures continues to shrink, even minor changes to benefits, service interruptions/disruptions, and operational “hiccups” can impact these ratings. At the same time, even minor (but well-publicized) improvements to benefits, service improvements, communications, and “winning moments” can influence these ratings.

The next 60 days are vital to your 2019 rating. Here’s a checklist to help ensure your 4th quarter work plan will be successful:

  • Be intentional. Successful Star Ratings leaders are those with vision, courage, and the wherewithal to tackle the right things and get them done. Because staff time and finances are our most precious resources, we need to make sure our Star Ratings leaders know what each person in the plan needs to do, can do – and then empower and educate them to do that well. Make sure staff and executives understand how far away you are from your goal, and be open about the investment that will be needed to get there. Prepare a data-driven work plan that improves performance on enough measures (and the right measures) to achieve your goal, and shore up performance on outlier measures to generate the largest possible reward factor.
  • Be very clear: ask the right people for exactly what you need. All too often, various teams within a plan make multiple, measure-specific phone calls to members and providers, but nothing causes more frustration and confusion for the member or provider. Use your data to identify the full picture of your “ask” of a member or provider, and establish a collaborative, cross-departmental prioritization of your “ask” across the full continuum of measures/needs. Don’t forget to check with your Risk Adjustment and Provider Relations teams to incorporate their needs into each ask so each member or provider knows exactly which actions you want them to take in the next 90 days and so your investments achieve your goal.
  • Don’t forget the homefront! Of course it’s important to conduct targeted outreaches to carefully chosen members and providers to close gaps in care, but it’s just as important to shore up certain internal issues. Make sure someone is accountable for identifying and resolving any missing claims, encounters, and lab results (and to resolve leakage from hard/soft rejects) and a highly-skilled expert verifies Healthcare Effectiveness Data and Information Set (HEDIS®) medical record review procedures capture all available nuances, which can bolster measure rates. Within the Pharmacy team, identify the person accountable for ensuring prescription drug events (PDEs) exist for all claims in the drug classes impacting Star Ratings measures.
  • Be honest. We often run across health plan staff who know they are wasting time, money, and effort with outdated tactics that are not accomplishing Star Ratings goals, but often their corporate culture simply isn’t conducive to discussing alternatives and changing course. Let the Star Ratings team serve as an open, transparent corporate improvement vehicle so the next few months can be spent leveraging what’s working, adjusting course wherever needed, and augmenting existing activities where needed for success. Once the 4th quarter press is underway, conduct a thorough, objective review of your 2018 Star Ratings performance to determine which activities and operations worked well, what didn’t work as well as planned, and to identify areas that can be improved or enhanced during 2018 to better support your Star Ratings vision.
  • Don’t forget your vendors! Despite the proliferation of vendors offering commodity-like, budget-friendly tactical support in recent years, many health plans are beginning to realize the inherent performance risks associated with business process outsourcing. Dedicate time in joint operating committee meetings to ensure each vendor is supporting Star Ratings needs effectively and contributing to your CAHPS® and Health Outcomes Survey (HOS) needs. Identify the person responsible (both internally and at the vendor) for each vendor’s cohesive, collaborative support of your members’ needs, and hardwire Star Ratings into all vendor management and delegation oversight activities.

Last, but not least, empathy has never been more important within Star Ratings. Never, in the history of Medicare Advantage, have so many beneficiaries lived in federally-declared disaster areas. From Texas to Florida, and from Louisiana to Puerto Rico, we know our members are hurting and in great need. From urgent relocations to long-term power outages, long delays awaiting home repairs, fear of dishonest neighbors and contractors, our beneficiaries have never needed more support. While we don’t yet know whether CMS will incorporate some type of administrative relief to plans operating in affected areas, we do know the way we approach Star Ratings in these areas will be a true test of our mission and commitment to our members. Make sure your staff know the definition of measure-level success – and they understand when the members’ broader needs may simply be more important than your measure needs. (And when that happens, capture the specific member and measure so you can request relief from CMS in upcoming feedback periods). Ensure every staff member has the tools, time, and skill needed to locate and support your members and help them connect with the full spectrum of care they need as we all recover from the storms.

Whether you need help developing a data-driven Star Ratings work plan or improving your organization’s Star Ratings, we can help. Contact me at to learn how we can help.



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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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