How to partner with health plans in January to maximize stars success
by Michael Jones
The Extreme and Uncontrollable Circumstances (EUC) adjustment from CMS, also known as Covid protection, has now expired, which means that the overall star ratings for health plans will not be adjusted to account for Covid. There was an overall decline in year over year star ratings over the last two years, with the national average star rating declining from 4.37 in calendar year 2021 to 4.15 in 2022, a decline of 0.22.
You might not be aware of this, but there is a substantial financial incentive to health plans for improving star ratings. Plans that score from 3.5 to 4.0 stars receive a 65% rebate percentage from CMS, compared to 50% for achieving 3.0 stars or less, and plans that score 4.5 to 5.0 stars receive a 70% rebate from CMS.
With the adjustments of guardrails protecting wide variations in cutpoints (a positive), and the quadruple weighting of several member experience measures (a risk or unknown), along with the incentive grading from CMS, health plans are even more acutely aware of the need for proactive planning and partnerships with physician practices.
When it comes to your Medicare Advantage patients especially, there are several things you can do right now that will allow you to partner with health plans more proactively and continue to serve your patients through 2023 and beyond.
First and foremost, recognize that you as the physician and the physician practice hold the relationship with your patients. Your patients trust you to help them with healthcare decisions and to navigate the sometimes frustrating phases of their health. Especially your seniors on Medicare and your dual eligible patients. You as the physician and the clinicians at your practice have established relationships, some of them spanning many decades and generations, and even when patients move between health insurance plans, you are their constant. With that honor comes both the power to impact your patients and their health in a positive way, and a responsibility to do what is in your best judgment as a physician.
Second, seek out your contacts at health plans to ensure they have a full picture of your practice and your patient panel. Attribution can be done a host of different ways, and especially if you have an incentive model with a health plan, understanding how a patient is attributed to you is crucial. Just as important is understanding how a patient can be de-attributed, or dismissed from your panels. Each health plan will have different parameters around both of these, and the first true step to planning for star success is ensuring you have the right patients.
Next, along with the health plan and your own analytics team, look at the history of those attributed patients, especially those who fell out of compliance for medication adherence measures in or before the 4th quarter of 2022. To get to a stars cutpoint, patients are “graded” on the basis of Proportion of Days Covered, or PDC. PDC is generally calculated as (sum of days covered in the period) / (number of days in the period) x 100. Cutpoints are assigned to different star ratings based on PDC.
As you’re likely aware from your health plan contacts, PDC is a time sensitive measure in that when a patient falls below the minimum cut point for a star rating level, there is no way that patient can mathematically become compliant in that calendar year. Health plans design their formularies so that prescriptions are affordable, and they offer mail order and pricing structures for 90 day fills.
Working with the health plan and your own team to identify those patients who have not been compliant in years past will be a starting point in your medication adherence efforts, and the physician and clinical team can address the need for certain prescriptions as well as use the behavioral interview process to identify any health literacy or cost barriers to patients filling prescriptions regularly.
Beyond those patients who fell out of compliance in prior years, it’s important to monitor patients' current full medication spectrum to ensure all medications are appropriate and being used in the dosage and manner indicated. Having regular reviews of current adherence rates can help you significantly, and, when this is done with health plans, it can be even more impactful.
Next, work with your health plans to identify patients in need of various screenings, such as colorectal cancer and mammograms. Both you and your patients understanding the need for these screenings and the options available to them can help you proactively serve your patients.
Finally, partner with your health plans on the patient experience measures (CAHPS and HOS), and establish a plan to work within the CMS guidelines to impact those subjective measures in a proactive manner. The way you as a physician and a practice interact with your patients, ranging from how long your patients wait in your office to specific wording of questions you ask, can be a major driver in those patient experience measures.
Approaching stars collaboratively with health plans can strengthen your relationship, have a direct impact on your incentive with the plans, if you have one, and can have a positive influence on your patient experience and outcomes. Understanding the value that you as a physician and physician practice add to the equation can give you satisfaction and results.
