Influencing Your 2021 Star Ratings: Every Day Matters

With last week’s release of draft 2020 Medicare Advantage Star Ratings to health plans, the now-annual “4th quarter Star Ratings fire drill” has officially begun again.  Among the many developments in the 2020 ratings, important highlights include:

  • HEDIS cutpoints show continued increases in performance.  With the exception of Rheumatoid Arthritis, Diabetes Care – Blood Sugar Controlled, and Plan All-Cause Readmissions, substantially all other HEDIS measures showed continued improvements.  Performance consistently improved across these measures, which are generally most easily embraced by providers and often are the most heavily invested in by plans, as evidenced by increases in some or all cutpoints. 
  • CAHPS cutpoints continue getting tighter:  The Rating of Health Plan and Rating of Drug Plan measures saw increases on most cutpoints, and others measure cutpoints remained fairly consistent.  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 ratings.   
  • HOS performance and cutpoints remain extremely erratic.  The 3x-weighted Improving or Maintaining Mental Health measure shows persistent national erosion in performance evidenced by decreases in all cutpoints, while performance bands tightened on Improving or Maintaining Physical Health with an increase at the 2 star cutpoint and a decrease at the 5 star cutpoint.  All cutpoints on the Monitoring Physical Activity measure declined, while all cutpoints on the Reducing the Risk of Falling measure increased.  Improving Bladder Control continues to frustrate plans who largely opt not to invest in this measure, resulting in persistent declines at all except the 3 star cutpoint.  The clinical recall measure of Annual Flu Vaccine, where plans are comfortable with interventions and continue pushing the bar for excellence,bucks that trend and shows increases at the 4 and 5 star cutpoint levels.
  • Heavily-weighted PDE measures show increased evidence of topping out.  Concurrent with the flurry of large-scale M&A seen among the PBM’s who support many efforts on these measures, performance across all plans is beginning to show evidence of topping out.  Cutpoints continue inching closer and tighter, with the greatest amount of fluctuation occurring it the across-the-board improvements in cutpoints on the Statin Use in Persons with Diabetes (SUPD) measure.  Based on the MTM Program CMR Completion Rate measure showing signs of normalizing this year, we should expect a few more years of rising rates and cutpoints on the SUPD before it normalizes as well.

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 8 weeks are critical.  But with only about 90 days remaining to connect members with the care they need for your success, every day, every member and every decision matter more than ever.  Here are a few tips to help you earn the ever-elusive 4th star:

  • Make sure you are adequately investing in CAHPS.  Now that the CAHPS and administrative measures are 2x-weighted, CAHPS comprises an almost equivalent portion of the overall Star Rating as HEDIS.  Are your investments of time and budget into CAHPS measures at least equivalent to your investments of time and budget into HEDIS?  If not, don’t forget you can influence CAHPS performance throughout the survey season. 
  • Make sure your 4th quarter workplan contains enough high-ROI activity to achieve your goal.  It’s easy to fall prey to “analysis paralysis” when the pressure is on, but it is vital to quickly ensure your 4th quarter workplan contains enough activities and interventions on enough (of the right) measures to achieve your goal.  Many plans are just now realizing how the increased weight of the CAHPS and admin measures, combined with retirement of several HEDIS measures, has changed the  nature and type of activities required in the immediate term.  Though many admin measures and all HOS measures are out of play for the 2021 ratings, there is plenty of time left to impact HEDIS, PDE, sales call center and CAHPS measures.  Make sure staff know exactly which members are still in play on in each measure, and prevent wasted effort by focusing tightly on the measure needs during “crunch time.”  
  • Focus on data capture.  Every year we hear from plans who miss the 4th star because they failed to capture all available HEDIS “hits”, PDEs and other data.  Unfortunately, much of this work must occur during the 4th quarter, when there are many competing priorities.  While clinical and provider-facing staff focus on interventions, identify someone to aggressively identify and resolve any missing claims, encounters, lab results, PDEs, SNF/inpatient stays, cash claims and other critical data.  
  • Ensure enough focus on lowest-performing measures. Improving a measure from 1 to 3 stars is generally much, much easier than improving a measure from 3 to 4 stars – and up to 8 times as impactful in the Reward Factor calculation.  Make sure your 4th quarter workplan doesn’t focus only on the measures closest to 4 stars; every incrementally higher rating can be the determining factor in your overall rating calculation.
  • Stop doing things that are not working.  This is the most difficult decision most of our clients face.  Don’t waste time, money or effort with outdated tactics that you know are not accomplishing Star goals – change course wherever needed before it’s too late!  If you aren’t sure whether something is working, measure it.  If you want to know what your competitors are doing, call outside experts for well-informed guidance.

If you achieved 4 Stars this year: There is ‘no rest for the weary.’  Many of our clients are new entrants to MA – and they are fierce competitors!  They understand what it takes to achieve 4+ Stars, and are counting on the Quality Bonus Payments associated with >4 Star performance.  The incremental effort you need to invest to compete with them may feel relentless, but keep it up!

If you did not achieve 4 Stars this year: Now is not the time to panic.  You still have time to influence your 2021 Star Ratings.   With a carefully planned 4th/1st quarter strategy backed by data and executed to perfection, you may be able to attain (or regain) your all-important 4th star.  You’ll need to carefully evaluate your current performance and use your time and resources wisely to hit 4 Stars.

Whether you need help developing or finalizing your 4th quarter Stars strategy or adapting to the innovations needed for longer-term Stars success, we can help.  For additional questions and inquiries about how GHG can support your Star Ratings efforts, please contact me at

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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