Medicare Advantage Star Ratings at Risk for 2023

By Cynthia Henry, Manager of Medicare Advantage Solutions at ZeOmega

Measure year 2022 saw record-breaking numbers of Medicare Advantage (MA) health plans achieving five-Star Ratings, but with pandemic adjustments—which focused on pre-COVID-19 data and significant changes to rating calculations since—2023 Star Ratings may be in for a drastic shift. Recent studies from Press Ganey indicate as much as 80% of MA plans are at risk for losing at least one Star Rating across 2023. The potential financial impact could mean reduced member benefits and less funding available for creative engagement campaigns. The result: lower retention rates.

Earlier this year in February of 2022, CMS published an Advance Notice of Methodological Changes for calendar year (CY) 2023 focusing on aligning policy with federal commitment to improve delivery of equitable healthcare for all beneficiaries. Health Equity seeks to improve availability of supports and services to underserved and vulnerable populations where ignored social risks threaten health outcomes. In anticipation of these codified changes to Stars, MA plans should not wait to begin aligning their social care and quality programs if they want to maintain ratings and prepare for enhanced regulations. Strong social care strategies may be key to overcoming the post-COVID-19, Star-Rating rebound.

What We Know Today About Member Experience and CAHPS Scores

CMS has already finalized changes to the member experience making measures in this category quadruple weighted for measure year 2022. Member experience measures have significant weight with respect to the overall health plan rating. Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys which prompt members to respond to questions about their experience with their health plan and providers are annually administered in the spring by certified vendors to a representative sample of the membership. Survey results are collected. Then, outcome data is mapped to CAHPS measures included in the Star program calculation. To begin understanding impact opportunities, we can dig into CAHPS survey statistics that uncover insights.

In general, several sources report that members with a positive perception of their plan are more likely to respond to surveys, but there are more important nuances to note. SPH Analytics reports 64% of the total average representative sample size will complete CAHPS surveys. If we look at how that breaks down in demographics above the average, we see the following groups responding at the highest rates:

The top responders for CAHPS are among the same demographic groups that Health Equity targets for social care campaigns. This presents a direct correlation between recipients of social care support services and CAHPS scores.

Expanding this correlation to an operational level, imagine the success stories health plans would have by aligning their social care campaigns with members that are most likely to respond to surveys! When Quality and Social Care teams collaborate to create new and exciting engagement solutions—you have a “win-win” for MA plans. Positive population outcomes and positive member perception are the result. PHM solutions like ZeOmega’s Social Care and Care Quality Navigator are a “must have” to achieve success with this type of approach. Because when you are working with centralized data in a single ecosystem that provides real-time data analytics delivered to cross-functional teams, you are in an excellent position to pinpoint challenges, take laser-pointed actions to solve them, track outcomes, and enhance success.

Looking to the Future and Ensuring Alignment with CMS Priorities

As MA enrollment grows to 45% of all Medicare enrollment with projections indicating more than half in the coming years, quality bonuses are also climbing uphill. Rising stakes make planning ahead for CMS’ intended inclusion of a Health Equity Index and SDOH assessment measure imperative to maintaining Star Ratings. CMS has collected feedback on three Health Equity proposals related to Stars:

  1. Health Equity Report- Enhancements to stratify social risks across all measures to identify opportunities for improvement.
  2. Health Equity Index- An enhancement to the Part C and D Star program which is intended to look across all Star measures to summarize social risks into a single score applied to the overall rating calculation.
  3. Health Equity Measure- A new measure developed to monitor a plan’s performance on administering SDOH assessments.

Although the finalization of these changes is likely to take time, there is no reason MA plans should not begin analyzing their processes, data, tools, and teams now. As stand-alone arms of the organization, quality and social care-focused teams may have different workflows, but the objective of creating value and optimizing outcomes is the same. MA plans should consider the following best practices for achieving success:

  1. Develop a Member Experience team encompassing leadership champions and experts from various sectors of the organization including quality, care management, physicians, and customer service who will bring varied perspectives to strategy discussions.
  2. Consider off-season CAHPS surveys to collect valuable data and make projections. Off-season surveying provides an opportunity for plans to collect far richer data and enables analysis of demographics, organization-specific services, and provider network performance.
  3. Adopt a PHM solution like the ZeOmega Health Cloud to centralize data across various sources including third-party vendors, community-based partners, CMS files, and census data into actionable analytics and workflows. Through layering data sources, teams can leverage varied data sets to discover opportunities and build data-driven strategies.
  4. Promote organization-wide awareness of each team’s role in improving outcomes. From administrative teams to clinical staff and call center representatives, each touch point with a member is an opportunity to engage and build a positive impression.
  5. Develop reports and dashboards to monitor performance, identify risks, and reveal trends the organization can immediately act on. Performance should be monitored against organizational goals and reviewed often.

As we continue to see the link between quality programs and social care becoming evident through policy changes, MA plans stand to benefit from a combined approach resulting in both Star Rating success and improved population outcomes.

Cindy Henry – Manager, Medicare Advantage Solutions

As the manager of ZeOmega’s Medicare Advantage (MA) solutions, Cindy Henry is responsible for product innovation and market expertise for Medicare and Medicare Advantage lines of business.

Cindy is a member of the Government Solutions team, providing subject matter expertise across all government-sponsored programs. She collaborates with other experts and clinicians to survey regulations, monitor policy changes, and research market trends to ensure ZeOmega’s products continue to meet the needs of its federal- and state-contracted clients.

Cindy began her career in the government-sponsored market in 2015 as a Business Intelligence Project Manager at North Texas Specialty Physicians (NTSP), an independent physician association and parent company of Care N’ Care, a Medicare Advantage plan in Texas. While at NTSP, she held several titles including business analyst, project manager, and interim manager for the Business Intelligence and Application Development teams. Before coming to ZeOmega, Cindy was the Medicare Advantage Product Manager for a PHM startup company.

Cindy received her Bachelor of Arts degree from the University of Texas at Arlington and is a Project Management Institute certified project manager.