Charting a 2015 Medicare Star Ratings Strategy

Feb 11, 2014
Express Scripts Constellation Ratings Advisor modeling program links Star Rating improvements to projected CMS quality bonuses and total plan performance.

To remain competitive and sustain a top-performing plan in the Medicare Advantage Prescription Drug Plan (MA-PD) and Prescription Drug Plan (PDP) marketplace, health plans must provide exemplary service, rising above today’s standards and planning for tomorrow’s higher performance thresholds.

Forty-five percent of Medicare beneficiaries chose 4-star and 5-star plans for 2014, compared to 37% in 2013. Also, starting in 2015, only the highest performing Medicare Advantage plans (4 stars to 5 stars) will receive quality bonus payments and from a considerably smaller bonus pool.

Chasing a Moving Target

The greatest challenge health plans face in achieving a high star rating is simply keeping up with how CMS measures a plan’s performance. CMS is not just adding measures; they are changing performance thresholds for existing measures and even retiring a measure, which means even a plan’s strongest performance measures may need continual improvement.

Here’s a look at what’s changing in 2015:

Charting a 2015 Medicare Strategy

Perhaps the biggest change announced is actually for 2016, yet requires immediate focus today from plans. CMS is moving toward completely eschewing defined four-star thresholds in favor of a 'clustering' methodology for determining Star scores.

Super Star Strategy

There are four elements to a successful strategy for star performance:

  1. Make quality a No. 1 priority
  2. Discipline
  3. Understand and manage your data
  4. Develop a plan using your data to identify what areas to improve and how to improve them

The new Express Scripts ConstellationSM Ratings Advisor can help plans pinpoint the most effective and efficient strategies to improve Star Ratings, and is the first tool to link those improvements to CMS Quality Bonus Payments, iFactor ratings and total plan performance.

Drawing on more than a decade of Medicare experience, Constellation addresses the four elements above by:

  • Capturing historical performance, and testing and modeling improvement scenarios
  • Setting goals for all 51 Part C measures and Part D measures
  • Identifying targeted high-impact improvements big and small that can drive total plan performance
  • Creating a roadmap for improvement across all plans to ensure ratings consistency and iFactor performance

With Constellation, health plans can expect improved understanding of their current Star Ratings performance and develop a blueprint to improve future performance.

The high performer’s challenge is to never stand still. The bar will continually rise, and plans must use every tool available to improve quality to avoid finding themselves on the wrong side of the 5-star seesaw that happened in 2013 while seven plans rose to 5-star status, another seven lost that status.

The plans that take strong, proactive action around improving the quality measures will succeed in this rapidly changing and highly competitive environment.

Constellation Ratings Advisor Overview

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