Ideas to Engage Providers and Patients in CMS 5-Star Quality Rating Improvement

Tuesday, September 17th, 2013
This post was written by Jessica Fornarotto

With an additional star in CMS’s Five-Star Quality Ratings System worth about $50 per member per month (PMPM),* health plans are anxious to polish their Medicare Advantage ratings. One area ripe for improvement is the management of chronic conditions, notes Joseph Johnson, vice president of L.E.K. Consulting — an area where both providers and patients can be recruited to help.

During a recent webinar on A Strategic, Best Practice Approach to Improve CMS Star Quality Ratings, suggested strategies for health plans to engage providers and patients in the management of chronic conditions.

Question: One area where health plans are struggling in is managing chronic conditions. What can health plans do to improve in this area?

Response: From a managing chronic conditions standpoint, operate under the guiding principle that these are in fact measures that are highly driven by the engagement of the provider network that a health plan utilizes. You also want to make sure that providers actually have aligned incentives, like creating profit-sharing goals for example, to the extent that a specific target for a given CMS Star Quality Rating measure within managing chronic conditions is met or exceeded, and then sharing part of the incremental revenue uplift with the providers that are part of that focused targeted improvement.

Also, provider report cards are another good tactic that we’ve seen health plans employ in order to help drive improved Star Ratings. Those are a couple of tactics that we’ve seen used in practices that did yield material results.

Question: Are there any success stories from plans utilizing house call programs to manage chronic conditions?

Response: We’ve seen a positive incremental yield on house call programs. Those programs can serve a dual purpose both with incremental revenue Star uplift, as well as an incremental improvement in coding initiatives and hierarchical condition categories (HCC) and Risk Adjustment Factor Type (RAFT) scores. To the extent that you know the algorithm is being used to target those house call programs are implemented effectively.

Question: Does the senior population participate in digital patient engagement programs?

Response: Yes, although many say that the senior population is not accustomed to digital communication channels. Increasingly, we’ve seen the senior population become more and more wired, so to speak. There are benefits for this type of communication channel; it can be an effective, low-cost way of engaging in some member outreach that can be effective, particularly when targeted at raising overall CMS Five-Star Quality scores.

Question: Can member engagement programs increase CMS Five-Star Quality Ratings?

Response: Certainly member engagement programs, when appropriately targeted and directed, can result in meaningful uplifts and improvements in Star Ratings. With the health plans that we’ve worked with, targeting mailings, telephonic outreach or other forms of outreach — with low performing member/provider cohorts — have been a great way of increasing overall performance in a way that does materially change and improve overall Star Ratings, to the extent that they are targeted efforts, as opposed to more far reaching or broad, blanket efforts across the entire member base. And the ROI and the yield are certainly higher.

*When moving from a three- to four-star Medicare Advantage plan, according to L.E.K. Consulting.

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