HEOPS Medicare Advantage Star StrategiesMEDICARE ADVANTAGE STARS: How Do You Move the Stars Ratings?

Copyright 7.29.2014: Scientific Cowboys – Nancy C Everitt, PMP

How hard is it to achieve a Medicare Advantage 5 Star Rating?

It’s no piece of cake, and many organizations are struggling not to be removed from the program for low scores. On the other end of the spectrum, Kaiser appears to have the answers with plans in 9 states rated at 5 Stars.

A quick refresher;  the 5 Star rating system was designed by the Center of Medicaid and Medicare Services (CMS), as a quality and performance scoring method used for certain Medicare plans.  In this case we’re looking specifically at Medicare Advantage.

The Star Ratings strategy supports  CMS’ triple aim (better care, healthier people/healthier communities, and lower costs through improvements) with measures that span five broad categories

1. Outcomes: Outcome measures focus on improvements to a beneficiary’s health as a result of the care that is provided.

2. Intermediate outcomes: Intermediate outcome measures help move closer to true outcome measures. Controlling Blood Pressure is an example of an intermediate outcome measure where the related outcome of interest would be better health status for beneficiaries with hypertension.

3. Patient experience: Patient experience measures represent beneficiaries’ perspectives about the care they have received.

4. Access: Access measures reflect issues that may create barriers to receiving needed care. Plan Makes Timely Decisions about Appeals is an example of an access measure.

5. Process: Process measures capture the method by which health care is provided.

Pushing the Levers for Star Change – How Do you Move the Stars?

5 Star achievement and management is a planned state. Achieving 5 Stars can be achieved using a project methodology and tools and techniques with measurable outcomes. From 2013 to 2014, no plans increased their ratings by more than 1 star. That’s right, zero and only 15 plans or 6 % of plans advanced a full star.

Okay, so how do you move the stars?

Below are 5 Critical Success Factors (CSF)  to advance your star rating; however I will caution you that these are hard work and require a commitment of resources and organizational focus.

1.  Concurrent Analytics Tool: Analytics software by itself will not move the needle, however with no software or software with a semi annual or quarterly refresh rate, Many MA organizations lack the ability to see how effective efforts are once implemented. MA Organizations appear to fall in the following categories related to Stars Analytics Software

  • No Analytics Tool or Internal Reporting that does not replicate CMS ratings methodology
  • Analytics Tool with semi annual or quarterly refresh rate
  • Analytics Tool with concurrent or bi weekly refresh – WOW!

2. Project Management Framework: Many MA organizations do have some form of formal or informal project management; however project management is relegated to special projects and IT. In our market analysis, HEOPS determined that formalized Project Management directed specifically at creating and maintaining an effective Project Plan around the Stars program is the X factor to creating sizable leaps. This is achieved through specific “work packages” targeting measurable results then managing this through the completion process.

Often we see harried VP’s trying to herd cats on extra projects that do not get completed.

3. Service Bureau Assistance: This will sound a bit strange for clinical VPs however the need to have deployable resources at the ready to meet targeted outcomes is a critical success factor. For example, a delivery pharmacy network to get meds to key patients that have not filled their meds to meet medication compliance. Need to set appoints for Mammograms etc, deploy call center personnel for 4 days. What about an HCBS network that has the right non skilled resources ready to help improve outcomes and preventable admissions? Don’t be afraid to think out of the box.

4. Simulation and Scenarios: Through the use of simulations tied to the measures, specific resolutions can be identified and aggregated to target the Star progression needed. You do this behind the scenes before you implement and are certain of the potential impact and number of patients needed for impact. Even better, drill down to your high impact patients.

5. Work Packages and Decomposition: What if you could decompose your simulations to specific patients and activities to enable your team or a service bureau to assist you in achieving these results?  It’s possible, just not available in most analytics tools or user friendly enough for the masses. We’ve worked with one tool that allows for decomposition so that work packages can be rolled into a project plan then allocated to internal staff or the service bureau.



While the 5 Critical Success Factors for moving your Stars rating forward are hard, they are also effective.

  • Project Management is the backbone of high performing organizations and can lead Medicare Advantage organizations toward Star increases. Specifically, lean, elegant, nimble project management and not lumbering, bureaucratic project management that is a process unto itself.
  • Analytics tools are necessary, but by themselves will not transform your organization. You must have a capable champion that is integrated within your project management process to interpret and assist in implementation.
  • Nimble organizations will be open to Service Bureau assistance and simulations for work package creation.

However at the end of the day,  if the organization lacks the discipline to execute, all is for naught.

Looking ahead to 2015 will any plans increase their ratings by more than 1 star? Perhaps, maybe  it’s your organization.

Good luck and reach out if you’d like to discuss strategy.


About the Author:

Nancy C. Everitt, MBA is the President and CEO of HEOPS, Inc. and Editor in Chief of Scientific Cowboys. Ms. Everitt is lead strategist to Clients’ on the design and fulfillment of patient access solutions such as network development and provider engagement, quality analytics, Medicare Advantage STARS strategy, disruption analysis and mapping. Ms. Everitt has been involved in the strategy of each engagement and provides significant perspective on industry best practice.

In addition to serving as Editor in Chief on Scientific Cowboys, Ms. Everitt is a frequent contributing writer to the publication sharing real world advice and operational insights on process and performance improvement. Questions on this article may be addressed directly to neveritt@heops.com.






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