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April 16, 2018

Since its launch in October 2016, the star rating system of Centers for Medicare and Medicaid Services (CMS) has been continuously updated to push payers (health insurance providers) into performing better. The rating itself is based on the performance of 47 individual measures, 32 from Medicare Part C and 15 from Part D. The rating system was charted by the CMS to help beneficiaries simplify the process of selecting the right healthcare provider as well as for allocating federal grants to top performing payers.

However, as the parameters for earning a full five star rating become more stringent, payers are finding it difficult to maintain their rating or earn a better score without stressing their bottom line. All 47 measures, which are evaluated for rating a payer come from variety of data sources such as Healthcare Effectiveness Data and Information Set (HEDIS), CMS, Consumer Assessment of Health Plan Providers and Systems (CAHPS), Health Outcome Survey (HOS), and independent CMS auditors. These basic measures are then translated into “stars” using a series of statistical tests – the weighted average being used to determine the quality bonus payment.

The High Cost of Better Ratings

The CMS star rating system is designed to benchmark payers based on common matrices that factor in competitive information about the strengths of other healthcare providers in the same space along with the technological and process improvements they have implemented to achieve better outcomes. For identified measures, they will also have to create a target patient profile and pick out patients from the member pool who could benefit from these and further improve ratings as a result.

Payers are therefore required to constantly investigate what their competitors are doing to gather intelligence, quantify performance targets, and identify industry best practice. Healthcare organizations often find themselves in a situation wherein their innovations are quickly appropriated and adopted by the competition as soon as they are introduced. Maintaining or even improving their CMS star rating, in such a scenario, means that they will have to keep improving their services at great cost.

Tracking and Measuring Improvements

Although there is no silver bullet capable of quickly remedying the situation, payers can leverage analytics to continuously improve and deliver outcomes, which help them gain better star ratings.

  • They can begin by building predictive models that can proactively identify the rating improvement trajectory much before the official results are announced by the CMS.
  • Analytics can also help payers build prescriptive models for measuring rating improvement if a chosen intervention or initiative is implemented.
  • In addition, it can assess the effectiveness and ROI of chosen initiatives at the enterprise level for improving star ratings targets.
  • At the patient-level, key measures can be identified and implemented for each patient who is a part of the health plan.
  • This will also help locate patients who need to be engaged with in order for the rating needle to move forward.
  • It can also be used to forecast which patients are at a high risk of specific needs such as breast or colorectal cancer screening.

Ultimately, analytics can enable healthcare providers to prioritize key measures improvement plan and make investments efficiently. This includes:

  • Aligning people, processes, technology, and infrastructure to arrive at the desired outcome.
  • Instilling a sense of ownership of the star rating process across the organization
  • Incentivizing associated activities to drive the change.
  • Following key processes for ensuring the effectiveness of continuous change management.
  • Updating training manuals regularly based on the latest CMS guidelines

Implementing a dashboard for measuring performance.

Payers also need workflow tools to ensure timely care delivery and implement relevant processes. Real-time analytics can not only help drive performance but also compare it with targeted outcomes to see if process improvement and innovation initiatives are moving in the right direction. Along with this, healthcare providers will also need a dedicated center of excellence to drive change and best practices.

Vickel Dubay is working as a Subject Matter Expert & Business Consultant for Life Science Analytics & Insight practice for TCS. He is catering the needs of top pharmaceutical & healthcare companies in the areas of Commercial Analytics, Development analytics, Supply Chain & Manufacturing Analytics etc. He has a blend of experience working with the companies like Novartis Pharmaceuticals, a core product company and companies like GlobalData, a core syndicated and custom research company. He has been in Life Sciences and Healthcare research & consulting industry for over 7 years.


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