Opinion and analysis on managing care from experts and KOLs

Improving Star Ratings Shouldn’t Be Just for Medicare

Norman S. Ryan, MD

Next year is a big year for Medicare Advantage plans. In 2015, they will not receive bonuses unless they have a 4-star rating or above. Many health plans are feeling under pressure right now, and may even feel a little disgruntled, as their businesses could really take a hit next year if they fall even slightly below 4.

One way to view this challenge that may take the edge off the pain is that the CMS Five Star Quality Rating System for Medicare Advantage Plans is not just about being able to stay or earn a spot in the Medicare Advantage program. Taking steps to improve ratings can help Medicare Advantage plans and other health plans hoping to enter the program achieve the Triple Aim and move them even closer to getting the business results they really want.

The Triple Aim, embraced by many health care providers, health plans, and policymakers, is:

  • Improving the patient experience of care, including quality and satisfaction
  • Improving the health of populations
  • Reducing the per-capita cost of health care

Medicare Advantage plans have always cared about making sure their members are managed optimally and receive the best care possible, which is what the star ratings are all about. HEDIS has been at the top of their minds for years. And plans have demonstrated a commitment to finding new ways to engage their members and reduce costs.

It’s just that now the pressure’s on to get it done a little faster, which should be good news because the payoff that we’ve all been working toward will come that much faster. And it doesn’t have to be that hard!

One key improvement that can have a broad impact on CMS ratings is to focus health management programs on helping patients remove personal barriers that keep them from complying and engaging in healthier lifestyles.

Helping patients remove barriers to adherence, for instance, can improve scores in a number of quality measures regarding chronic-condition management. The cost of non-adherence to drugs is estimated at $100 billion a year. A diabetic patient able to improve compliance by 10% can reduce medical costs from 9% to 29%. Providing the kind of compassionate, personalized assistance that helps patients discover underlying causes of their behavior can go a long way toward not only improving adherence today, but sustaining healthy behavior change into the future.

Providing members with access to personal interactions with people who really care − who are taking the time to understand the patient and his or her personal issues and how to address those issues − can also affect other measures, such as screenings, tests, and customer service.

Improving star measures is really about improving the patient experience. A well-managed, satisfied patient is a cost-effective patient, not just today, but for the long-term.

Norman S. Ryan, MD, has been senior vice president for health intelligence at Alere Health since August 2013. Earlier, he was senior medical director at Rush Health, the physician hospital organization at Rush University Medical Center in Chicago, where he is now an assistant professor. Previously, he was national medical director for medical management programs at United Healthcare. Ryan has also been senior medical director of Humana Health Care Plans in Illinois and Northwest Indiana, accountable for all lines of business as well as a 220-physician multispecialty medical practice and hospitalist program.

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