Star Ratings Update: MedPAC Votes to Eliminate Double Bonuses

Star Ratings is already a hot topic in 2016, and we’re only one month into the new year.  In most recent news, the Medicare Payment Advisory Commission (MedPAC) unanimously voted last month to eliminate the double bonuses associated with Star Ratings, while also virtually unanimously voting to exclude diagnoses collected during in-home assessments from the Medicare Advantage Risk Adjustment model. Although the Centers for Medicare & Medicaid Services (CMS) may opt to take an alternate approach to resolve Risk Adjustment issues within Medicare Advantage, and since CMS can’t independently remove double bonuses with amending certain elements of the ACA legislation, this new development is a great reminder of the need to periodically pause and evaluate the value and ROI of programs which remain prominently placed on CMS’ radar screen.

When CMS continued their support of in-home assessments in the 2016 Call Letter, we all breathed a collective sigh of relief.  And since that announcement, we have seen significant effort by both health plans and vendors to make these assessments even more clinically and socially focused while simultaneously aligning them with Star Ratings measure needs.  As a result, any strategic changes made in response to MedPAC’s January votes could have a pervasive impact on the care models and operational structure health plans have come to rely on for Star Ratings success. CMS’ response to MedPAC’s recommendations, along with the plethora of other potential Star Ratings program updates may not only impact health plans and providers, but could also impact a wide array of health services purchased through vendors.

Many health plans (and their vendors) have leveraged risk assessment work streams to hardwire carefully-planned and strategically-prioritized clinical care and care planning activities into in-home assessment workflows in order to seamlessly impact Star Ratings and achieve multi-faceted return on investment (ROI). In addition, the data collected during risk assessments is often stored in centralized data warehouses and used throughout the health plan as a foundation for population health, care management, and consumer experience strategies.  And if that wasn’t enough, because members often value the relationship with, and advice received from, the clinician they allow into their home, any changes to in-home assessments introduce a host of new risks relative to self-care and disease management, member satisfaction, and consumer experience.

As we await guidance from CMS regarding their response to MedPAC’s recommendations and regardless of how CMS ultimately responds to both issues, this is a great time for leadership to study and thoughtfully consider a number of decisions which could result from either the elimination of double bonuses or changes to CMS’ treatment of in-home risk assessments:

• What is the downstream Star Ratings impact of any benefits proposed for reduction or elimination?
• How have quality, medical management, pharmacy, Star Ratings measure gap closure, member retention, and other strategic priorities been hardwired into in-home risk assessments?
• What is the secondary ROI from in-home risk assessments on Star Ratings measures, health outcomes, medical loss ratio (MLR), member satisfaction, and member retention?
• Are current work streams adequate to support strong 2016 performance on new Star Ratings measures under consideration for addition to the Star Ratings program?
• How is each department using the data collected during in-home risk assessments?
• How well positioned is the provider network to serve the care planning and care management needs of members currently receiving in-home assessments?
• What types of alternative workflows and tactics will be used in the event diagnoses obtained from in-home assessments are not allowed for risk adjustment purposes?

Because time is of the essence in our industry, strategic planning and change management never ends. As John Gorman has said for years, it will be the most adaptable plans which will both survive and thrive through the tumultuous industry evolution.

In-depth analysis and industry-leading commentary on the key announcements from CMS and MedPAC can be found in this recently created white paper.

Gorman Health Group (GHG) can help you adapt your Star Ratings approach to account for these potential changes and streamline your Star Ratings strategy to influence health outcomes while remaining compliant with CMS regulations.  For additional questions and inquiries about how GHG can support your organization’s Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.

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