Primer: CMS Star Ratings for
Medicare Advantage Plans
Your group/presenter
Date
Stars Background
• P4P for Medicare Advantage Plans
• CMS developed in 2007 for Part C and Part D
• MA plans awarded 1-5 stars at the contract level
– 36 Part C and 17 Part D measures individually rated and
rolled up to a plan star rating
• Ratings posted on www.medicare.gov Medicare Plan
Finder
• Beneficiaries and CMS can assess plan performance
• Plans can earn through performance what they are losing
in prospective cap rates…CMS is eliminating the 14%
advantage MA plans have had over FFS
Stars Significance – “The Carrot”
• Congress mandated that CMS use star ratings
beginning in 2010 to reward high performing
plans with quality bonus
• Starting in 2012, plans with 4 or more stars
receive bonus and higher rebates
• Four star plan bonus: 2012 = 1.5%, 2013 = 3%,
2014 = 5%
• Group contracts are a % of MA premium so
plan overall performance affects all groups
Stars Significance – “The Stick”
• Plans with 3 or less stars for 3 years will be
flagged as consistently low performers on the
Plan Finder at medicare.gov
The Big MA Stars Picture
Focus In and Next Steps
Part C Measures Groups Can Impact
P4P HEDIS measures
Health Outcomes Survey® *
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Breast Cancer Screening
Colorectal Screening
CV Cholesterol Screening
Monitoring Patients on Long-Term Medications
Diabetes - Cholesterol Screening
Diabetes - Kidney Monitoring
Diabetes - Blood Sugar Control
Diabetes - Cholesterol control
Non-P4P HEDIS measures
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Glaucoma Testing
Access to Primary Care Doctor Visits
Osteoporosis Management
Diabetes Eye Care
Controlling Blood Pressure
Rheumatoid Arthritis Management
Testing to Confirm COPD
Improving Bladder Control
Reducing the Risk of Falling
Osteoporosis Testing
Monitoring Physical Activity
Improving or Maintaining Physical Health
Improving or Maintaining Mental Health
CAHPS® **
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Annual Flu Vaccine
Pneumonia Vaccine
Ease of Getting Needed Care from Specialists
Doctors Who Communicate Well
*The Health Outcomes Survey® (HOS) is administered by CMS annually to obtain data for the first four measures in the table. The results are based on patient recall for
each topic. Ratings for the last two measures are derived from responses to questions administered bi-annually to the same cohort of members. Functional status
results from the baseline survey are compared to responses on the follow-up survey to assess decline in functional status. Functional status questions are based on
patient perception of physical and mental health status.
**The Consumer Assessment of Healthcare Providers & Systems® (CAHPS) is administered annually by certified survey vendors hired by health plans. The first two
questions in the table rely on patient recall of flu and pneumonia vaccines rather than administrative (claim/encounter) or medical record review data.
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Where We Stand – Clinical Measures
• Display your group’s performance
dashboard(s) here
Prioritize – Meteor Program Path
• 2011: HEDIS measures - emphasis on non-P4P
– All measures equally weighted
– 2011 performance drives 2013 bonus
• Small denominator measures
• Clinically significant measures
• Health plan priority measures
• 2012: CAHPS and HOS
– Patient recall measures
– Patient experience
2011
• Measure priorities for 2011 outreach
– Rheumatoid Arthritis Management
– Spirometry for New COPD Diagnosis
– Osteoporosis Management
– Breast Cancer Screening
• Focus on centralized outreach this year
• Improve data exchange between group and
health plans (standard format from plans)
Discussion – Action Plan