Star Ratings: 10 Years, 10 Lessons

The Star Ratings program celebrates its 10th birthday this year. In honor of the first decade of quality ratings systems within managed care, and to celebrate the many lessons we’ve learned during these formative years of the Star Ratings program, here are 10 of our top lessons from the first 10 years of the program.

1. Success is not easy. Not only are Star Ratings constantly evolving, but the ever-changing regulations and Centers for Medicare & Medicaid Services (CMS) guidelines surrounding Medicare Advantage and Part D prescription drug benefit plans and the increasingly competitive Star Ratings environment make Star Ratings success a continuous, often challenging battle. Evolution is difficult, and every detail matters.
2. One size does not fit all. Every health plan has a unique culture, strategic plan, and relationship with its members and providers. And every health plan has a unique combination of vendors, analytical tools, systems, and business decisions that support its culture and strategic vision. As a result, every Star Ratings work plan is similarly unique. Customization, personalization, and tailoring is vital for success.
3. All healthcare is local. Every provider network is unique and has a unique combination of systems, tools, programs, priorities, and business decisions through which it provides clinical services to your members. And every group of members presents its own unique prevalence of conditions, expectations of local physicians, and social and lifestyle patterns. As a result, every Star Ratings work plan is unique.
4. Social determinants of health are a lynchpin to achieving and sustaining high quality ratings. Critical gaps between clinical care and community services exist in the current healthcare delivery system. CMS Innovation Model tests are underway to systematically identify and address the health-related social needs of beneficiaries while evaluating their impact on total healthcare costs, improved health, and quality of care. Star Ratings success on challenging triple-weighted measures is far easier accomplished when plans simultaneously support the clinical, social, and lifestyle needs of their members.
5. Easy, understandable, and contextually-appropriate requests (of members and providers) are most successful. Systems work best if they are kept simple rather than made complicated; Star Ratings is no different. Whether we are asking our members or our providers to take action, simplicity should be a key goal and external-facing, unnecessary complexity should be avoided.
6. Converting “big data” into “actionable intelligence” is key. Include carefully selected clinical, pharmacy, and Health Risk Assessment data elements for efficient, holistic success.
7. Member and provider interactions and programs are most successful with carefully targeted investments. This requires data-driven strategic planning, close alignment of routine operations with Star Ratings measure needs, and consistent execution of well-planned processes.
8. Manual workarounds and tactics likely won’t sustain success over the long term. When data and reports are manually built or Star Ratings-impactful activities occur outside of system-driven workflows, Star Ratings success isn’t easily scalable. As the principles and foundation built during the first 10 years of Star Ratings expands into the Health Insurance Marketplace, Medicare Fee-for-Service, and managed Medicaid, this is an excellent time to reengineer any manual activities into sustainable workflows.
9. The physician-patient relationship is the foundation for high-quality healthcare. Support members’ physician relationships wherever possible and augment where/how needed by developing personal relationships between carefully-selected members and a care coordinator.
10. “Best Practices” are often claimed as “best” before they have been carefully evaluated for wide-scale adoption. And don’t forget — a best practice is only a best practice until it becomes standard practice.

For questions or inquiries about how Gorman Health Group can support your organization’s Star Ratings efforts, please contact me directly at msmith@ghgadvisors.com.

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