To achieve a 5-star rating, Medicare Advantage plans need to master many skills, draw on their own experience, integrate with providers, glean insights from data and those already at the top need to demonstrate continued improvement just to remain there.
"We've been 5 stars four times now," said Donnie Aga, MD, medical director of Houston-based KelseyCare Advantage and an internal medicine physician for the medical group.
KelseyCare Advantage, which is integrated with the Kelsey-Seybold Medical Group, has received 4.5 stars for Part C Medicare Advantage, 5 stars for Part D prescription drug coverage and a 5-star rating overall.
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And for KelseyCare, the key to keeping their 5 stars is that commitment to constant improvement.
MA gaining momentum
MA began as an alternative to fee-for-service Medicare and has been growing as more insurers enter the market and, as a result, Medicare Advantage enrollment has roughly doubled over the last nine years.
More than a third of the Medicare-eligible population is now in an MA plan. CMS is encouraging the trend by offering insurers flexibility in Medicare Advantage and Part D plans and most recently, in its MA value-based insurance design model.
Three-quarters of Medicare Advantage-prescription drug program enrollees are in plans that have four stars or greater, according to CMS in its release of star ratings this past October.
The highest 5-star overall rating is important because consumers look at the scores when shopping for a Medicare Advantage plan, they are tied to bonuses and benchmark rates, and they can make a difference in having a year-round open enrollment period.
"One of the more interesting findings from the star ratings, the longer the contract, the better the performance," said Amy Salls, director of Population Health Strategies for DST Systems in Birmingham, Alabama. "The plans that do well tend to be more integrated with their providers across all departments of responsibility."
That's exactly what's working for KelseyCare.
The medical group has owned its own MA health plan since 2008, and the MA population of about 30,000 is in a narrow network of some 400 providers on one common medical record, Epic.
Kelsey-Seybold also provides its own drug plan that results in both control and high performance in Part D measures.
All of the nurses, doctors, lab techs, pharmacists and others are connected by organizational data, business intelligence and effort.
"We're all linked together which leads to a higher quality of care," Aga said. "We're in the same boat, rowing in the same direction."
The culture of the health system is such that a patient who shows up for a sick visit is given a reminder about an overdue vaccine or AIC blood test if one is due.
"We spend a lot of time and resources on intelligence and data so we know where the care gaps are," Aga said. "We know within three days if a patient hasn't gotten a prescription. The number one reason for being readmitted is being confused about medications."
After a discharge, the patient is set up for an appointment to be seen by his or her primary care physician within seven days.
"To me the common thread for groups that are 5 stars is a narrow network, ACO model," Aga said.
This isn't always possible.
"If we can get payer information and member information and provider information into a system, that's the best possible recommendation," said Mark Nathan, CEO and cofounder of Zipari in Brooklyn, New York.
Without that network, one way to improve is better customer satisfaction, according to Nathan, whose company focuses on capturing clinical and plan data for use in the insurer call center.
"There's just so much room for improvement there," Nathan said.
Even plans without a narrow network of integrated providers can improve their scores by having a better member experience, one of the measures the Centers for Medicare and Medicaid Services uses to determine the 1-to-5 star rating.
Patient experience matters
The Consumer Assessment of Healthcare Providers and Systems survey plays a big part in star ratings. The surveys measure a patient's interaction with a health plan, from calling in for membership information to filing claim forms.
The patient experience when calling in must be tailored to the specific person, not just based on his or her medical record, Nathan said. Some members may appreciate a reminder to fill their prescription or to get a flu vaccine, while others may not like their health insurance company giving them a medical recommendation.
"There's a lot of power I see in bringing this all together," Nathan said. "You're absolutely improving outcomes if you're speaking the right language to the member and improving the patient experience."
Health plans need to ask themselves when looking at their customer relations management, Salls said, were the members' concerns resolved completely?
"You can't maintain the old performance and still get star ratings," Salls said. "We saw that this year. I think they start to realize, it's not simply the clinical measures."
Star ratings are important to an insurer's revenue because they affect a plan's bid against CMS benchmark.
When plans contract with CMS to participate in Medicare Advantage, they submit a bid rate that is used as a comparison to a benchmark rate. When plans hit 4 stars, their benchmark rate goes up by 5 percent, Salls said. Plans are allowed to bid up to 5 percent more.
This allows plans to enhance benefits, waive copays, or offer a gym membership.
Preparing for next year and the one after
Staying on top is not just a question of staying the course. Part of the 5-star rating and 5 percent quality bonus is the improvement factor.
KelseyCare has a team planning at least two years into the future. And it's next challenges are patient engagement and quality measures.
Aga said patient engagement is its biggest area of continued improvement. To that end, the medical center is holding health events for seniors and provider fairs.
Success breeds success. Because 5-star plans can enroll patients all year round, in fact, KelseyCare has that advantage as a patient recruiter.
Looking ahead to next year, Aga is concerned that CMS's new rule around access standards so consumers have less driving time to see a provider, would require Kelsey-Seybold to add more physicians. The bigger the system, the less control over the narrow network.
"If I have to add more providers," Aga said, "my quality goes down."
And so the next challenge for KelseyCare's 5-star team and committee is to create an action plan to keep quality measures high.