Which CMS 5-Star Quality Domains Are Best Candidates for Improvement?

Wednesday, March 5th, 2014
This post was written by Jessica Fornarotto

CMS Five-Star Rating

With an additional star in CMS Five-Star Quality Ratings System worth about $50 per member per month (PMPM), according to L.E.K. Consulting (when moving from a three- to four-star Medicare Advantage plan), health plans are anxious to fine-tune operational processes and improve their rankings. Joseph Johnson, vice president of L.E.K. Consulting, shares which of CMS’ Five-Star Rating categories could be improved.

There is some data that indicates that certain CMS Five-Star Ratings domains or categories are better candidates for improvement than others. All Medicare Advantage (MA) plans score similarly to the top 10 MA contracts, and perform better on measures directly under their control — particularly member experiences with health plans, member complaints and appeals, and customer service.

Given the relative underperformance of measures in managing chronic conditions, we believe this is an area ripe for innovation and improvement from prioritization initiatives. CMS has recognized the opportunity to further improve the measures under ‘managing chronic conditions’ and has increased its emphasis by weighting these measures more heavily relative to other domain areas.

Now I’d like to discuss how to best identify CMS Five-Star Quality Rating improvement initiatives in a rigorous and systematic manner, by looking at sample data from the performance of an HMO MA product, with thresholds for the three-, four- and five-star scores. Within a given CMS Five-Star Quality Rating measure, individual members or provider segments are seen within a given MA contract.

When looking at which providers do well, which ones see a large base of membership, and also more importantly, the measures where skew may exist across the member-provider segments or cohorts, the end goal is to drive overall performance to the next threshold. Diabetes/cholesterol control and diabetes eye exams are seen as potential good member and provider cohorts to focus on for targeted improvement opportunities. This approach lays the foundation for how to prioritize targeted star improvement efforts.

Excerpted from: A Strategic, Best Practice Approach to Improve CMS Star Quality Ratings, a 45-minute webinar

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