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Medicare Advantage Star Ratings
December 2017
The Star Rating System measures how well Medicare Advantage (MA) and its prescription drug plans perform for
consumers. As an integrated health system, Presbyterian proactively manages quality improvement projects and
initiatives that directly impact MA Star measures and the resulting ratings.
The Essentials
• The MA Star Rating is a reflection of the quality of care provided to Medicare Advantage members.
• The quality bonus payment awarded for a MA Star Rating of 4.0 or higher depends on the overall
collective Star Rating calculated from as many as 44 measures. The bonus payment can be significant
and is used to further improve members’ care.
• Presbyterian Health Plan (PHP) monitors each of the MA Star measures and collaborates with care
teams in Presbyterian Delivery System (PDS) as well as community Providers to address gaps in care with
their Medicare patients.
Success and Impact
In 2016, Presbyterian received an MA Star Rating of 4.5 for PHP’s Presbyterian Senior Care (HMO) plan, which
resulted in a quality bonus payment. While the MA Star Rating for 2017 dipped to 3.50, it improved to 4.0 for
2018, which will impact revenue in 2019. (See page 8 for trends in Presbyterian’s MA Star Ratings.)
What We Know About Medicare Star Rating System
The Medicare Advantage (MA) program gives Medicare beneficiaries the option to enroll in a private health plan
rather than receiving benefits in the traditional fee-for-service (FFS) system. Virtually all beneficiaries have
access to such plans and may enroll when newly eligible for Medicare or during an open enrollment period.
Every year the Centers for Medicare & Medicaid Services (CMS) publish Star Ratings as an evaluation of quality
and service of MA and prescription drug plans. These ratings are meant to assist beneficiaries in choosing the
best plan for them, as well as to award additional payments to plans that meet high standards. These payments
are used by plans to provide additional benefits to members or to reduce cost sharing — which may then factor
into a beneficiary’s choice of MA plans. The Star Ratings program is also meant to drive improvements in the
quality of plans. As a result, CMS continues to see increases in the
number of Medicare beneficiaries enrolled in high-performing MA plans. For more information, contact:
Tom Rothfeld, MD
Furthermore, CMS has extended Star Ratings to hospitals, nursing homes, VP, Chief Medical Officer, PHP
and dialysis facilities, to support improvement in the quality of care trothfeld@phs.org
provided by those facilities. The focus of this summary is on Star Ratings
awarded to the Medicare Advantage Organization (MAO), which Beth Tibbs
Chief Operating Officer, PMG
administers one or more MA contracts.
etibbs@phs.org
© 2017 Presbyterian Healthcare Services | 1PHS | MA Star Ratings
Medicare Advantage contracts with prescription drug coverage (MA-PD) are rated on as many as 44 unique
quality and performance measures. These measures span five broad categories including outcomes,
intermediate outcomes, patient experience, access, and process. Measures are categorized and weighted.
Altogether, the weighted measures are used to calculate a relative quality score using a 5-star rating system,
with 5 being the highest and 1 being the lowest score.
Since 2013, there has been year-to-year
Figure 1. Average Star Ratings increase in average star ratings, together
for MA-PD Contracts with reduced incidence of low ratings,
5 4.03 4.02 4.06 suggesting that many plans have put
3.71 3.86 3.92
4 considerable effort into improving
performance on the range of measures.
3
2 MA Star Ratings are based primarily on data
1 collected on performance measures drawn
2013 2014 2015 2016 2017 2018 from five sources: HEDIS (Healthcare
Effectiveness Data and Information Set), HOS
(Health Outcomes Survey), Health Plan CAHPS (Consumer Assessment of Healthcare Providers and Systems),
CMS administrative data, and Prescription Drug Event (PDE) measures for MA-PD plans.
MA Star Ratings are not without controversy. Analysts have raised questions about how differences among
beneficiary characteristics and demographics affect Star Ratings. In addition, from year to year, CMS has
redefined performance benchmarks by changing thresholds on some measures, making it difficult for Health
Plans to plan for and achieve successful outcomes.
Star Ratings are published each October prior to the open enrollment period in the “Medicare & You” handbook
and on the Medicare website. These publicly reported results help beneficiaries choose a Medicare health
and/or prescription drug plan, and allow the public and research community to assess Medicare program
performance.
MA plans have a keen interest in the Star Ratings they receive — and the measures used to determine them —
not only because these ratings measure how well they are serving their members, but also because the results
can directly affect how much Medicare pays them, and in turn how much they can offer their enrollees. MA
plans receive a monthly capitated payment from CMS, which is intended to cover beneficiaries’ Part A and Part B
services. This amount reflects the relationship between a benchmark established by CMS and the amount bid by
the plan. Plans that bid below the benchmark set by CMS for a beneficiary population retain a share of the
savings, termed a “rebate,” which must be used to provide additional benefits or reduced cost sharing to
beneficiaries. The rebate percentage varies from 50% for plans with fewer than 3.5 Stars to 70% for plans with
4.5 or more Stars. Under a provision of the Affordable Care Act (ACA), plans with Star Ratings of 4.0 or higher
earn a quality bonus payment (QBP). While the amount may vary depending on the county involved, the
predominant QBP is 5%.
In 2017, 170 of the 384 active MA-PD contracts (approximately 73% of total MA enrollees,) scored 4.0 or higher,
and thus they were eligible for the bonus. Fifteen plans achieved 5 Stars in 2017. While there is no additional
© 2017 Presbyterian Healthcare Services | 2PHS | MA Star Ratings
financial incentive for achieving 5 Stars, five-star plans have the advantage of accepting beneficiary enrollment
at any time during the year, rather than only during the annual open enrollment period.
For plan year 2017, Presbyterian achieved MA Star Ratings of 3.5 for Presbyterian Senior Care (HMO) and 3.5 for
Presbyterian MediCare PPO.
The reporting/rewarding schedule for Medicare Star Ratings follows a three-year cycle. For example:
For services provided MA Star measures are which sets the overall which impacts the
during all of: reported in: Star Rating for all of: premiums in:
2015 2016 2017 2018
2016 2017 2018 2019
2017 2018 2019 2020
For services provided in 2016, Presbyterian’s 2018 MA Star Ratings are 4.0 for Presbyterian Senior Care (HMO)
and 3.0 for Presbyterian MediCare PPO. The HMO Contract qualifies for a 5% bonus, which will impact premiums
in 2019. (See page 6 for more about the process of MA Star data reporting; see page 7 for trends in
Presbyterian’s MA Star Ratings.)
The MA Star system is not a typical pay-for-performance program. Since CMS does not directly pay the
Providers, but instead pays insurers offering private coverage to Medicare beneficiaries, the reward is actually
paid to intermediaries in the provision of care. Thus, in order to earn a reward, the intermediary MAOs must
inform the Providers who see the MA enrollees as to the specific quality and performance measures being
evaluated.
Presbyterian Health Plan proactively manages initiatives around each MA Star measure, to provide tools and to
promote interventions that Providers may use to engage in quality improvement processes.
© 2017 Presbyterian Healthcare Services | 3PHS | MA Star Ratings
How PHS Manages Medicare Star Measures
Presbyterian is committed to providing quality care and services that meet or exceed CMS quality measures. In
order to monitor MA Star measures, the PMG Quality Improvement team organizes the measures according to
the data sources.
Medicare Star Measures by Source
Adult BMI Assessment (ABA)
Disease Modifying Anti-Rheumatic Drug (DMARD) therapy for Rheumatoid Arthritis (ART)
Breast Cancer Screening (BCS)
Colorectal Cancer Screening (COL)
Comprehensive Diabetes Care (CDC)
A1C Poor Control - >9.0%
HEDIS
Nephropathy Screening
Retinal Eye Exam
Controlling Blood Pressure (CBP)
Osteoporosis Management in Women who had a fracture (OMW)
Medication Reconciliation after Discharge (MRP)
Plan All Cause Readmission (PCR)
Improving or Maintaining Physical Health
Improving or Maintaining Mental Health
HOS
Monitoring Physical Activity (PAO)
Reducing the Risk of Falling (FRM)
Improving Bladder Control
Getting Needed Care
Getting Care Quickly
Customer Service
CAHPS Survey
Rating of Health Care Quality
Rating of Health Plan
Care Coordination
Annual Flu Vaccine
Rating of Drug Plan
Getting Needed Prescription Drugs
Members Choosing to the Health Plan
CMS Administrative
Complaints about the Health Plan
Plan Makes Timely Decision about Appeals (Part C)
Appeals Auto-Forward (Part D)
Reviewing Appeals Decisions (Part C)
Appeals Upheld (Part D)
Beneficiary Access and Performance Problems
Call Center – Foreign Language Interpreter and TTY Availability (separate measures for Part C and Part D)
Medicare Price Finder Price Accuracy
Prescription
Drug Event
Medication Adherence for Diabetes Medications
(PDE)
Medication Adherence for Hypertension (RAS Antagonists)
Medication Adherence for Cholesterol (Statins)
Medication Therapy Management (MTM) completion rate for Comprehensive Medication Review (CMR)
In addition to the measures listed above, two additional Quality Improvement Measures are assigned a Star
rating. One is for Part C (Medical) measures, and the other is for Part D (Pharmacy) measures. These highly
weighted measures are based on year over year improvement for selected measures.
© 2017 Presbyterian Healthcare Services | 4PHS | MA Star Ratings
Each of these measures is assigned to an “owner” who proactively manages initiatives around the measure. The
owner works with partners (PMG Providers, community Providers, vendors, etc.) as necessary to
improve/maintain measure outcomes.
For example, to improve the prevalence of colorectal cancer screening among patients and members, PHP uses
a HEDIS report to identify members who are imputed to PMG Providers and who may be due for screening. The
PMG care teams can use these imputed member lists to verify potential gaps in care. Using the resources of the
Patient-Centered Medical Home, PMG care teams encourage patients to get the recommended screening test
and follow up with patients showing a positive test result.
All workflows related to MA Star Measures are monitored by The Performance Improvement Steering
Committee, which includes measure owners from both PHP and the Presbyterian Delivery System, along with
analysts and key leaders. This committee meets monthly to coordinate performance improvement for both MA
Star and Centennial Care performance measures. It reports to the Presbyterian Integration Leadership Team
(PILT).
SERVICES TECHNOLOGY PEOPLE
Compile and report data related to Process Owners:
Epic EHR: used by the delivery
MA Star measures
system to document patient care, Director, Performance
Identify patients with gaps in care; provide order sets and standard Improvement, The Quality
share this information with protocols (and supporting tools), Department of PHP;
Providers and collect quality data including
Chief Operating Officer – PMG
HEDIS; the Healthy Planet module
Identify stakeholders in patient (Beth Tibbs)
helps to identify patients with gaps
care (e.g., care teams, pharmacy,
in care HEDIS and Star Program Director
claims processors); determine their
(Elaine Haemmerle)
impact on quality of care Facets™ system: a care
management tool used by PHP to Analysts
Make Providers aware of MA Star
identify patient-members with HEDIS Program Managers
measures; recommend
gaps in care, or in need of care
interventions to impact PMG Nursing Directors
interventions
performance
Providers
Develop interventions to improve
specific MA Star measures: Care Managers
• Provider outreach/incentives
• Member outreach/rewards
• Improved data management
• Other systems improvements
© 2017 Presbyterian Healthcare Services | 5PHS | MA Star Ratings
Process
There is a complex process for compiling, reporting, and forecasting outcomes data for MA Star measures.
Some data sources (such as HEDIS) can be monitored throughout the calendar year (CY) while others (i.e., Health
Plan CAHPS survey and HOS) are reported once per year, and just one month before Star Ratings are assigned,
making it more difficult to track progress and predict results. Moreover, HOS evaluates a cohort of members
over a two-year time span, which makes its results asynchronous with the rest of the measure sources. For
example:
Used to
calculated Determines
Measure performance Are submitted to Star Rating Star Rating For Payment
Source: data collected during: CMS: assigned in: for: during:
HEDIS CY 2016 Jun 2017 Oct 2017 2018 2019
HOS May-Aug 2016 Sep 2017 Oct 2017 2018 2019
CAHPS Feb-May 2017 Sep 2017 Oct 2017 2018 2019
CMS Admin. CY 2016 Jun 2017 Oct 2017 2018 2019
PDE Measures CY 2016 Jun 2017 Oct 2017 2018 2019
Given the difficulty in predicting Star Rating performance for both HOS and CAHPS Survey, analysts have found it
significantly challenging to forecast accurately an overall Star Rating.
© 2017 Presbyterian Healthcare Services | 6PHS | MA Star Ratings
Measures of Success
Objective Measures Aligns with Aim
Maintain MA Star Rating • Weighted Star – Overall Star Rating Better Health,
≥4.0 • Weighted composite, according to data source: Exceptional Experience
o HEDIS Measures
o HOS Measures
o CAHPS Measures
o CMS Administrative Measures
o PDE Measures
The forecast of the Weighted Overall MA Star ratings (for both HMO and PPO contracts) is reported monthly on
both PHP and PDS Board scorecards. Only 23 measures (out of 44) — those that have outcomes data reported
on a regular basis — are included in this forecast calculation. Current forecasting methods account for less than
53% of the overall weighted Star rating.
In addition, individual measures are grouped according to data source, and scores are weighted according to
CMS formulas. These composite scores, as well as individual measure scores, are shared regularly with the
Performance Improvement Steering Committee.
Trends in MA Star Ratings
For the 2018 MA Star Ratings, Presbyterian saw an increase in MA Star Ratings for several measures, including:
• Diabetes Care – Kidney Disease Monitoring (HEDIS)
• Improving or Maintaining Mental Health (HOS)
• Customer Service (CAHPS
• Overall Rating of Healthcare Quality (CAHPS)
• Getting Needed Prescription Drugs (CAHPS)
• Plan Makes Timely Decisions about Appeals – Part C (Administrative)
• Foreign Language Interpreter Availability (Administrative)
• Part C Quality Improvement
Although the individual Star Rating did not change, Presbyterian saw improved results for several measures. This
improvement contributed to the Part C Quality Improvement measure. This highly weighted measure is assigned
a Star based on year over year improvement for selected measures.
Measures showing improved results include:
• Colorectal Cancer Screening
• Osteoporosis Management in Women who had a Fracture
• Diabetes Care – Eye Exam
• Complaints about the Health Plan
Page 8 shows trends in MA Star Ratings for both Presbyterian Senior Care (HMO) and Presbyterian MediCare
PPO over the last five years.
© 2017 Presbyterian Healthcare Services | 7PHS | MA Star Ratings
The PHP HMO contract
Weighted Star - Overall Rating HMO PPO
4.45 achieved 4.0 or higher for
4.10 3.64 3.65 3.77
3.52 3.53 3.56 3.53 3.24 services provided in 2014
and 2016.
2012 2013 2014 2015 2016
HEDIS measures are
Weighted Star - HEDIS Measures
4.25 3.88 designed to assess a
3.80 3.81 3.56 4.00 3.82
3.2 3.25 3.18 plan’s clinical
effectiveness,
accessibility to members,
and use of resources.
2012 2013 2014 2015 2016
HOS asks the member to
Weighted Star - HOS Measures
self-report their health
4.50 status.
3.75 3.63
3.00 2.88 3.00 2.88 3.00 2.67
2.25
2012 2013 2014 2015 2016
The Health Plan CAHPS
Weighted Star - CAHPS Measures
survey assesses the
4.19 3.96 3.54
patient’s satisfaction
3.38 3.19 2.96 2.85 3.19 3.5
2.5 with both their health
plans and their network
providers.
2012 2013 2014 2015 2016
These measures reflect
Weighted Star - CMS Administrative Measures
member interactions
5.00 5.00 4.57 4.57 4.57 4.57
4.00 4.00 with CMS such as call
3.36 3.14
center performance,
volume of complaints,
and beneficiary
disenrollment.
2012 2013 2014 2015 2016
These measures reflect
Weighted Star - Pharmacy Event Measures
member experience with
4.00 4.00 4.00 3.75 4.23 4.54 3.92 3.85 drug plan, drug pricing,
3.60 3.70
and pharmacy-related
patient safety.
2012 2013 2014 2015 2016
© 2017 Presbyterian Healthcare Services | 8PHS | MA Star Ratings
Changing Thresholds
CMS made changes to rating thresholds which impacted the overall Star rating for 2018. For example, in three
measures (Breast Cancer Screening, Controlling Blood Pressure, and Adult BMI Assessment), Presbyterian’s Star
Rating decreased by 1 Star, even though the performance rates improved or stayed the same.
Future Work
Presbyterian’s integrated work plan for managing MA Star measures intends to guide the organization towards
achieving 4.0 or greater Star Ratings. The work plan articulates both short- and long-term goals.
Short-Term
Complete interventions during Q4 of 2017 that will impact 2019 MA Star Ratings, specifically:
• Designate ownership for all MA Star measures, including HEDIS, CAHPS and HOS measures
• Conduct bi-weekly Performance Improvement Committee meetings with a focus on select priority
measures:
o Diabetic Measures (Eye Exam, Kidney Screen, A1cPHS | MA Star Ratings
Glossary
gap in care Gap in care (or “care gap”) is a term used widely throughout patient health analytics to
recognize a disparity between health care needs or recommended best practices and the
services that have actually been provided. Gaps in care may be those outstanding office
visits, lab tests, procedures, and pharmaceuticals that a patient needs, but have not yet
received, usually because there are obstacles. A successful Population Health program
gives real-time insights to both clinicians and administrators, allowing them to identify
and address gaps in care within the patient population. According to CMS: “There is a
need for all providers to work actively to continuously monitor and address disparities,
and to be accountable for reducing gaps in care and outcomes. All CMS beneficiaries must
have access to and receive person-centered, equitable, effective, safe, timely, and
efficient care and services.”
HEDIS The Healthcare Effectiveness Data and Information Set (HEDIS®) is a tool used by more
than 90 percent of America’s health plans to measure performance on important
dimensions of care and service. Altogether, HEDIS consists of 81 measures across 5
domains of care.
HOS The Medicare Health Outcomes Survey (HOS) was designed to gather valid, reliable, and
clinically meaningful health status data in the Medicare Advantage (MA) program for use
in quality improvement activities, pay for performance, program oversight, public
reporting, and improving health. All managed care organizations with Medicare contracts
must participate. The HOS is administered annually to a random sample of Medicare
beneficiaries drawn from each participating MA plan and surveyed in the spring (i.e., a
baseline survey is administered to a new cohort, or group, each year). Two years later,
these same respondents are surveyed again (i.e., follow up measurement). The survey
asks the member how they have been feeling, both physically and mentally, during the
four weeks prior to the survey.
CAHPS The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a
multi-year initiative of the Agency for Healthcare Research and Quality (AHRQ) to support
and promote the assessment of consumers’ experiences with health care. The CAHPS
Health Plan Survey is a tool for collecting standardized information on enrollees’
experiences with health plans and their services.
Medicare Star Developed by the Center for Medicare and Medicaid Services (CMS), the Star Rating
System (also called “MA Star”) measures how well Medicare Advantage (MA) and its
prescription drug plans perform for consumers. MA Star ratings serve several purposes: to
measure quality in Medicare Advantage and Prescription Drug Plans, to assist
beneficiaries in finding the best plan for them, and to award MA quality bonus payments.
In addition, CMS has extended Star Ratings to hospitals, nursing homes, and dialysis
facilities, to support improvement of the quality of care provided by those facilities. CMS
rates MA contracts based on a range of as many as 44 unique quality and performance
measures, with data gathered from a variety of data sources, including standard HEDIS,
CAHPS, and HOS measures. Altogether, the weighted measures are used to calculate a
relative quality score using a 5-star rating system, with 5 being the highest and 1 being the
lowest score.
© 2017 Presbyterian Healthcare Services | 10PHS | MA Star Ratings
Additional References
Clinical Care Model
• Colorectal Cancer Screening
• Patient-Centered Medical Home (PCMH)
Resources: PHS login required
• Medicare Stars - CAHPS® Member Experience – 2017 Results
Additional Resources
• 2017 Star Ratings (CMS)
• Medicare & You 2018: Medicare handbook
• Part C and D Performance Data (cms.gov)
• The five-star rating system and Medicare plan enrollment (medicareinteractive.org)
• Star Ratings: Measures and Definitions (medicare.gov)
© 2017 Presbyterian Healthcare Services | 11You can also read
