Navigating the CMS Star Ratings Shake-Up: How to Improve Your Rankings
By Aurora V. Adams, MS, CHCA Senior Quality Consultant, Toney Healthcare
If your plan took a hit to your CMS Medicare Advantage (MA) Star ratings in 2023, you’re not alone.
While CMS provided reasonable notice of the new and improved statistical methodology used for the ratings released this past October, results hit some plans by surprise. Many saw their Star ratings decrease—and have the challenge of explaining the optics of this decline to their stakeholders.
So, what happened?
The most recent (and future) CMS MA Star ratings employ the Tukey method, a statistical technique for identifying outliers in a data set. Outliers, i.e., data points that differ significantly from the rest of the data, can potentially skew the result of statistical analysis. The Tukey method helps to detect these outliers and eliminate them from the calculations, in this case with the goal of increasing the statistical validity of the Star ratings.
In practice, we saw that once the outliers on both sides of the performance spectrum were eliminated during the latest calculations, the scores for many plans dropped relative to their counterparts, with a corresponding change to their Star ratings.
With these changes, it’ll be even more important to make quality performance a central part of your strategy in 2024.
The Impact of Declining Star Ratings
It’s clear that highly rated plans have significant competitive advantages. Not only can 5-star plans expand their membership at any time of the year, but they share in the savings generated by value-based care models and often receive higher reimbursements. These benefits give them a competitive advantage, enabling them to attract higher-tier providers, and their enhanced negotiation power may help them secure more favorable financial arrangements.
Plans with declining ratings, on the other hand, not only face the potential of damaged reputations and eroding member trust, but also leave money on the table—reimbursements they may have received in the past but will not receive in the coming year. Some plans who have performed at a certain level have come to rely on the revenue and will need to make up the shortfall in other ways. And, all plans can expect some member attrition to higher-rated plans, further impacting revenue and plan viability.
Developing a Strategy to Increase Your Star Ratings
While many plans try fourth-quarter pushes to improve quality scores, these programs generally don’t have much of a positive effect. It is difficult to close care gaps when members face factors outside a plan’s control such as holidays and appointment availability. Instead, plans should focus on areas they can control:
Analyze your processes—Assessing your quality programs can help you identify opportunities for improvement and reduce waste so that your processes are efficient, adequately staffed, and support your goals for timeliness and quality metrics.
Improve measurement and data collection—Make sure the data you’re collecting is complete and accurate and the measurement systems are as airtight as possible. The difference between 5-star plans and 2-star plans may not be fully attributable to care quality—if they are using the same networks, they may be largely delivering the same care. The disparity may be that the 5-star plan is better at measuring and leveraging data to report on and improve their quality programs. You still have enough time to impact your 2023 measurement that is due in June.
Plan now so you can hit the ground running in early 2024. Now is the time to boost your performance over 2023’s results. You can make a real difference for measurement year 2024.
But what happens if you don’t have the resources—or the expertise—to improve your quality scores? That’s when you call in reinforcements.
Quality Experts to Improve Quality Performance
Whether you need help evaluating and improving your quality program or clinical resources to help you meet your quality metrics, Toney Healthcare has you covered. We offer a wide range of experts—including quality leadership, nurses, physician reviewers, and other clinical resources—that have deep expertise in NCQA, CMS, URAC, and other quality programs and can help you improve your quality performance by:
Evaluating and retooling your processes to improve efficiency and ensure your resources are being used in the best way possible way.
Analyzing your data and reporting strategies to make sure the information you collect supports the quality metrics you need to measure in a way that is digestible, actionable, and maximizes Star and other regulatory performance measures.
Help you put the people, processes, data and technology in place so you remain in compliance with your quality program requirements.
Support audit and accreditation efforts through readiness assessment, process analysis, project management, staff training, on-site support and corrective actions.
For more information, on Toney Healthcare’s quality program expertise, please visit our Quality Advisory Services Overview.
