Big Changes Coming to Star Ratings in CMS’ Part 2 Advance Notice & Proposed Rule

On February 5, 2020, the Centers for Medicare & Medicaid Services (CMS) released Part II of the Advance Notice of Methodological Changes for Calendar Year (CY) 2021 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (Advance Notice) containing its annual rate notice. Simultaneously, CMS issued the Contract Year 2021 and 2022 MA and Part D Proposed Rule containing a variety of non-rate-related changes in program policies, regulations and guidance. Though there are significant changes proposed across a variety of areas, this article will focus exclusively on changes associated with Star Ratings.

CMS has proposed numerous changes to the Star Ratings program, some of which are significant and others more detailed. CMS indicates the proposed changes will save the Trust Fund ~$4.4B over 10 years, largely from Quality-Based Payments (QBPs), which are decreased through reduced Star Ratings. We suggest paying close attention to these proposals, as changes like these appear to represent one of the key levers CMS will use to extend the solvency of the Trust Fund.

Below are the significant changes to Star Ratings for the 2021 measurement year:

  • Increase in weighting of Patient Experience, Complaints and Access measures from weights of 2x to weights of 4x. Measures impacted include CAHPS, Disenrollment, Appeals, CTMs, Call Center and Complaints measures. CMS indicates that this change supports the growing consumerization of healthcare, and that more contracts would see their ratings increase, rather than decrease, due this change.
  • Adoption of Tukey outer fence outlier deletion as an additional step prior to hierarchal clustering for non-CAHPS measures (running comparable prior year data so that guardrails can be applied as proposed previously). This has the important impact of changing cutpoints, particularly in the 1-, 2- and 3-Star ranges. CMS indicates more contracts would see their ratings decrease, rather than increase, due to this change, and indicates that this change will drive the cost savings touted in the CMS announcement’s headline.
  • Addition of 2 new Part C HEDIS measures:
    • Transitions of Care (including nonsubstantive changes also presented)
    • Follow-up after Emergency Department Visit for Patients with Multiple Chronic Conditions
  • Removal of Rheumatoid Arthritis Management (ART) measure.
  • Implementation of substantive updates to the 3x-weighted Improving or Maintaining Physical Health and Improving or Maintaining Mental Health measures, which would presumably cause them to temporarily retire the Display Page for at least 2 years beginning in measurement year 2021.
  • Reclassification of the Statin Use in Persons with Diabetes (SUPD) measure as a Process Measure, rather than as an Intermediate Outcomes measure, which changes the measure weight back to 1x-weight beginning with the 2021 measurement year.

The new codification approach used by CMS to increase the stability and transparency of program changes has been welcomed by plans. Though, it’s fair to say that even just the sheer number of new measures, retired measures and changed measures (both those that are known and those proposed this week) is not only unprecedented, but has also made it hard for health plans to distinguish proposed changes from those changes which have already been codified.

Here’s a quick calendar of where we are with new measures, retired measures and significantly adjusted measures including this week’s proposals. (Known changes in GREY and proposed changes in GREEN):

In addition to numerous nuanced program changes (which we’ll describe in a separate blog) and various measure-specific technical adjustments, a few additional noteworthy proposals presented for comment include:

  • Considering adoption of PQA’s risk-adjusted Medication Adherence measures (which were endorsed by NQF in Spring 2019) as future Star Ratings measures for MY2022 or beyond. This change would be considered substantive and must be implemented through rulemaking. Since measures with substantive changes are retired to the Display Page during their transition, adopting these changes would dramatically alter mid-term strategic planning in the coming years.
  • Required disclosure to CMS of the measures used to evaluate pharmacy performance, as established in the plan’s network pharmacy agreement (and any financial implications associated with such measures). This information could be collected for future public disclosure and use by the industry to develop, test and achieve consensus on a set of potential future Star Ratings pharmacy performance measures which would ensure standardization, transparency and fairness.
  • Adoption of the failure to achieve at least a 3-Star Part C or Part D summary rating as a basis to deny an application based on past performance. For the many new MA entrants with rapid, sizeable expansion plans—which are often acted on even while the new plan is struggling to stabilize its own Star Ratings performance—this change may expedite the Stars efforts of new plans and/or slow the planned pace of expansions by some plans.
  • Addition of new measurement areas, including some emerging new areas such as biosimilar utilization, initial opioid prescribing, Net Promoter Score-like CAHPS measures, cardiac rehabilitation, among others.

It is worth nothing that, unlike in prior years, CMS will not be publishing a Call Letter for 2021. CMS is proposing to codify much of the guidance typically included in the annual Call Letter through the rulemaking process. Comments on the proposals set forth in the Advance Notice must be submitted by Friday, March 6, 2020. The final 2021 Rate Announcement will be published by Monday, April 6, 2020.

Throughout this week’s documents, CMS continues reiterating their desire for feedback, comments and thoughts on these proposals. They have a long history of not only reading every bit of feedback received, but also incorporating feedback into their final decisions.

While we await more concrete decisions on these proposals in the coming months, we urge plans to begin preparing for these changes. Even if not implemented in 2021, efforts in the proposed areas are known to have positive ROI across many KPIs outside of Star Ratings. The likelihood is that some version of many of these proposals will eventually be included in the Star Ratings program.

For more information regarding the impact of these potential program changes on your organization, contact Melissa Smith at msmith@gormanhealthgroup.com.

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.

1 Comment
  1. Quick calendar you have displayed shows that ART is to retire in 2020, yet Federal Register states proposal states that its for 2021 measurement year (see pg. 155)

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