Star Ratings: The Drive to 5

A Focus on Member Experience Can Get Your Plan That 5th Star

With healthcare trends shifting as the coronavirus pandemic continues its evolution, there’s one issue in particular that will most heavily impact Medicare Advantage (MA) health plans going into 2022 and beyond: the increased weighting of member experience measures as part of the plan’s Star Rating. Since CMS announced its changes to the methodology of calculating MA quality scores in May 2020, customer experience and access measures alone are growing as a substantial share of that rating. And that share is only getting bigger!

The Final Rule published by CMS in December 2020 set the scene for the dramatically increased importance of member experience to Star Ratings. And despite year over year scores being relatively flat from 2018 to 2019, followed by a global pandemic, SPH Analytics found there was actually an uptick in the nation’s overall member satisfaction scores (2-4%) during the 2020 calendar year. This upward trend ran parallel to CMS’s decision to increase the importance of member experience in its Final Rule.

The road to a 5-Star rating is paved with member experience

Even in the healthiest of times, the road to the much sought-after 5-star rating has never been an easy one. The quest for 5- and even 4-Star ratings, has always been long, winding, and detail-rich. Even now as a slowly healing nation still contends with the Delta variant of the coronavirus, healthcare organizations (and CMS) realize the paramount importance of the patient/member experience as its spotlight continues to grow brighter. 

Take a look at 52% of healthcare CIOs who have now elevated patient experience as their new number one priority, overtaking former top guns artificial intelligence and machine learning. And no fewer than 81% of payer, 49% of provider, and 91% of pharmaceutical executives have prioritized the customer experience for years to come, in addition to their own investments in customer experience technology.

The areas where key progress is evaluated by CMS 

Here’s where the changes to MA Star Ratings changes come in:

1. Improving the patient experience of care (quality, access, reliability)

  • Shift in focus to member experience
  • Increased weight of experience & access measures

2. Improving the health of populations

  • Retirement of easier to achieve outcomes measures and addition of measures that ensure coordination of care delivery and population health management (e.g. Follow-up After Emergency Department Visit for People with High-Risk Multiple Chronic Conditions [FMC]), Transitions of Care [TRC])

3. Reducing or controlling the cost of healthcare

  • Many of the Star Ratings changes are for cost savings purposes and to preserve the Medicare Trust Fund

How the configuration of Star Ratings will shift

Breaking it down, here are the compositions of the Star Ratings and how their elements will re-weight over the next several years.



HOS Star Rating update

CMS announced in early August 2021 that two HOS outcome measures (Improving or Maintaining Physical Healthand Improving or Maintaining Mental Health) will not be used in the 2022 and 2023 Star Rating calculations. CMS cited the validity of these two models being compromised during the COVID-19 pandemic, preventing CMS from accurately measuring change in beneficiary health status over time for either measure. Read the full CMS memo.

There’s much more to uncover on your Drive to 5

Your Drive to 5, however, merely starts here. Watch the free webinar Star Ratings Updates: A Focus on Member Experience for more information about how to improve your ratings.

Enhancing the member experience can often be quite the challenge. By directing your energies to a targeted outreach incorporating insightful predictive analytics, you’ll be retaining more members with higher satisfaction, getting members to close care gaps and fill their prescriptions, and driving more meaningful impact on outcomes – all big components of a 5-Star rating. We call it Smart Member Engagementand look forward to discussing implementing it with your plan. Contact us here for more info or to schedule a demo.


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