When CMS implemented the Five-Star Quality Rating System, the agency aimed to improve the quality of care and strengthen protection for beneficiaries. Using a scale of one to five stars, these ratings gauge how well a given healthcare plan (payer) covers a patient and meets federal guidelines and recommendations on patient care and services.
Reviews are published online at the Medicare Plan Finder, which not only keeps the system accountable, but also helps patients stay informed while easing the burden of comparing health plans. This system wields significant influence over the Medicare system—but perhaps not as much as it could. According to a 2018 survey by HealthMine, less than one quarter of beneficiaries even know the ratings exist, much less how they impact the quality of their healthcare.
Nevertheless, the star rating system plays a serious role in improving health insurance payers’ performance. Healthcare plans with better ratings tend to attract more members, so there’s a built-in incentive structure to the rating system. Those plans that work to promote and improve their star rating are positioned to capitalize on the opportunity to develop better processes and thus service patients more effectively.
A road map for improved offerings
To provide objective measurements for evaluating health plan quality, CMS uses no fewer than 48 quality measures among five categories, with the most weight sitting in care management — think breast cancer screenings, annual flu vaccines, diabetes care, etc. Additional categories rely more on what a health plan itself can control—areas such as member complaints and changes in plan performance.
One question to ask is: How well are payers performing against this robust set of metrics? To paint a picture of the industry’s star performance, McKinsey analyzed CMS’s data covering 530 Medicare Advantage health plans. It discovered that the overall enrollment-weighted average star score in 2017 (4.00) changed only slightly from 2016 (4.03).
Furthermore, McKinsey’s report confirmed that plans with four or more stars are more likely to see stronger enrollment growth than those below that threshold. Of the 2014 contracts (Medicare/Medicaid contracts that can contain multiple plans) that were still in the market in 2016, those that retained at least a four-star rating experienced nearly 41% growth. Meanwhile, contracts that lost a four-star rating experienced only 8% growth, and contracts that consistently performed below four stars had less than 1% growth.
There is a strong correlation here between the rating and enrollment success. If that’s not enough to embrace the Five-Star Quality Rating System as a route to plan improvement, here are three more reasons to support it.
- It fosters a collaborative environment. The star rating system weighs provider-influenced outcomes above all else, but it also has a major impact on beneficiaries’ choices of healthcare plans. This relationship encourages collaboration between providers and healthcare plans to invest in better processes and technologies to improve outcomes, which will improve plan ratings and encourage greater enrollment.
- It transforms administrative work into a revenue source. Administrative work can seem like nothing more than a cost sink and a drain on resources, but the star rating system can help turn it into a revenue source. The more a payer invests in back-end services such as claims processing, enrollment, and member engagement, the more likely it is to improve its rating and expand its consumer base.
- Customer service will become more important as plan differentiation saturates. Customer service and member experience are key parts of the star rating equation. The plans that stand out will be those that improve the ways providers engage with beneficiaries. Those that give the customer the most pleasant interactions will be those that ultimately look better and score higher.
Putting it all together
OK, so you buy into the value of the rating system. What should you do next? Here are three concrete steps that health insurance carriers can take to increase their star ratings:
- Encourage plan members to utilize their covered services. For healthy patients, this includes things such as anual physical exams, preventive health screenings, and vaccines. For patients who manage chronic diseases, administrators should actively encourage them to maintain the recommended frequency of doctor’s appointments and stick to the prescribed course of treatment. It’s important to share information about the patient’s illness and provide tips on how to manage it most effectively. The healthier plan members are, the better the plan’s star rating.
- Prioritize the user experience. The star rating system is heavily weighted toward the experience of health plan members, so it is in a carrier’s interest to offer added convenience wherever possible. That can be done very effectively by offering intuitive websites and mobile apps where members can easily pay their bills, find in-network providers, schedule appointments, file complaints, and get general information about their plan.
One of the biggest issues consumers have with health plans is denial of coverage. It’s very important that consumers have access to the information they need and that they receive accurate and fair assessments of their coverage.
- Communicate, communicate, communicate. Customer service is another huge area of concern for star ratings. Administrators would be wise to offer online FAQs, chat support, and 24-hour phone support to ensure they’re providing optimal customer service to members. Don’t just offer passive support, though. Administrators can make billing clear and easy by sending text reminders when the bill is due—or even helping members set up autopayments. Automated appointment reminders, health outcome tracking, and clear plan details can also play an important role in providing great customer service.
The Five-Star Quality Rating System isn’t just a mechanism to improve the patient experience; it has also changed the industry from an insurer’s perspective. When providers buy into the CMS rating system as a means to continuous improvement, they too will benefit.
Austin Gispanski is vice president, business strategy of Exela Technologies, a global business process automation leader providing enterprise software and services to more than 3,700 customers worldwide.
This article was originally published on ManagedHealthcareExecutive.com January 16, 2019