The main aim of this document is to provide a high level understanding of the Star rating quality program of CMS and it’s impact on plans (at contract level) offered by the payers which are in Medicare Advantage line of business It describes the various measure categories and their weightages, domains and sources required by CMS to assess quality of care and patient experience.

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CitiusTech Thought
Leadership
Maximizing Performance Incentives
Through Star Ratings
19 September, 2017 | Author : Vivek Singh| Healthcare Business Analyst
CitiusTech Thought
Leadership

2. 2
Objective
 The main aim of this document is to provide a high level understanding of the Star
rating quality program of CMS and it’s impact on plans (at contract level) offered by the
payers which are in Medicare Advantage line of business
 It describes the various measure categories and their weightages, domains and sources
required by CMS to assess quality of care and patient experience
 At the end of this document readers shall be able to:
• Identify areas for improvement in their own or their client's Medicare Advantage
Star rating
• Describe key components of the Star rating
• Understand what is required to improve and/or maintain a Star rating

3. 3
Agenda
 Overview of the CMS Star 2017
 CMS Star Rating Measure Details and Timelines
 Calculating Star Ratings and Financial Incentives
 Difference between CMS Star 2016 and 2017
 Impact on Health Plans
 Recommendations
 References

4. 4
Healthcare Regulation – CMS Star 2017
Objectives
 It enables Medicare beneficiaries to
compare quality among Medicare
Advantage Plans on the Medicare
Prescription Drug Plan Finder (MPDPF)
 Strategic goal is to improve the quality of
care and general health of the Medicare
beneficiaries
 It also aims at reducing the per capita
costs of care for population
 Increase accountability of health plans
for quality of care by providing
incentives for improving quality
Stakeholders
 Payers
 Health plan contracts
 Health maintenance organizations
(HMOs)
 Integrated delivery networks (IDNs)
 Preferred provider organizations (PPOs)
Overview
 The CMS uses a Five-Star quality rating
system to measure Medicare beneficiaries’
experience with the health plan and the
health care system (for Medicare Advantage
(MA) Part C and Part D prescription drug
plans only)
 CMS rates Medicare Advantage plans on a
scale of one to five stars, with five stars
representing the highest quality
 Star ratings as well as scores on individual
performance measures are published by CMS
every year
 As part of Healthcare reform, CMS gives
quality bonus payment to MA plans based on
the Five Star ratings
 Ratings are given to the respective plans of
contract of payer organizations

5. 5
CMS Star Measure Details (1/4)
For 2017 CMS Star ratings, 47 quality measures are taken from other measure sets such as
 HEDIS (Healthcare Effectiveness Data and Information Set)
 CAHPS (Consumer Assessment of Healthcare Providers and Systems)
 CMS administrative data on plan quality and member satisfaction
 HOS (Health Outcome Survey)
 IRE (Independent Review Entity)
Five broad measure categories and their weights

6. 6
CMS Star Measure Details (2/4)
CMS Star Measure Domains
Medicare Advantage – Part C (32 measures)
 Staying healthy: screenings, tests, and vaccines (preventives)
 Managing chronic (long term) conditions
 Ratings of health plan responsiveness and care
 Member complaints, problems getting services and choosing to leave the plan
 Health plan customer service
Drug Coverage – Part D (15 measures)
 Drug plan customer service
 Drug pricing and patient safety
 Member experience with drug plan
 Drug plan member complaints, problems getting services and choosing to leave the plan
Click here to refer to Measure list for CMS star 2017

7. 7
CMS Star Measure Details (3/4)
CMS Star Display Measures
Plans not just require to work towards Star Measure improvements (i.e. for incentives and
rebates) but also towards Display Measure improvements which are used for monitoring quality
improvements by plans or as a staging area for measures prior to them becoming a Star rating
measure
 51 Display Measures for 2017
• 27 Part C Display Measures
• 17 Part D Display Measures
• 7 Common Part C & D Display Measures
 Not part of the Star ratings calculations and are displayed for informational purposes
 Poor scores on some display measures are subject to compliance actions by CMS
Click here to refer display measure list for 2017

8. 8
CMS Star Rating Timeline (4/4)
October
Nov - Dec
Late Fall
Early Spring
Spring
Late Spring
Late Summer
Early Fall
Appeal period for
changes in published
Star ratings and QBP
(Quality Bonus
Payment) begins
Display
Measures
Draft and Final Call
letter sent for next
year’s changes in
Star ratings done
by CMS
QBP Appeals
period ends
User Group Call
presentation:
Discussion on final
specs and changes
made by CMS in Spring
Collection of Measures’
data and calculation of
domain, summary, and
overall Star ratings
Medicare Plan
Finder(MPF) changes
for any Star ratings
changes as a result of
QBP Appeals
Ratings
publicly
released
2nd Plan Preview/Comment
Period: Draft technical
specifications
1st Plan
Preview/Comment
Period: Measures
'data collection
only to prioritize
Plans’

9. 9
Calculating Star Rating (1/2)
 Each Medicare contract of a health plan in a region is assigned a number of stars for each of the
individual qualitymeasures
 The stars for the individual measures are averaged to get overall summary score for the contract
 The individual quality measures are risk adjusted for patient characteristics
 Summary of Star rating used to determine a quality bonus is derived from multiple rating levels:
• Individual measures level: measures for quality and performance are evaluated and each
individual measure is assigned a Star rating
• Domain level: related measures are grouped together and each domain is assigned an
average Star rating
• Summary level (derived separately for Part C and Part D contracts): Parts C and D contracts
each receive an adjusted average Star rating assigned to each contract
• Overall level: A combined overall rating summarizing quality and performance for all Part C
and Part D measures is given to MA-PDPs contracts
• This rating represents an adjusted average of both Part C & D individual measure stars
combined into a single Star rating
In addition to individual scores assigned to quality measures, plans are rewarded
for consistent quality across all measures.

10. 10
Calculating Star Rating (2/2)
CMS will evaluate the Medicare Advantage health plans on the following reporting areas by
assessing performance on Medicare Part C measures and/or Medicare Part D measures which are
taken from other measure sets as mentioned below:
CMS-MA-Star Rating : Reporting Requirements
Medicare
Part C (36
measures)
Combined
Measure Set
Data Reporting Areas
Measure
Sources
Medicare
Part D (18
Measures)
HEDIS
IRE
CMS Others
HOS
CAHPS
Quality
Responsiveness
and Care
Preventive Care
Member
Experience
Chronic
Conditions
Customer
Service
Drug Pricing and
Patient Safety

11. 11
Financial Incentive Payment
 Financial incentives tied to Star ratings fall in two categories:
• Rebate Payment - is the amount the plan receives depending on the plan’s Star rating which
must be used to provide extra benefits to enrollees
• Quality Bonus Payment(QBP) - helps to improve the overall revenue of the contractor of
Medicare Advantage plan
 Both these incentive payment are calculated as a share of the Medicare Advantage benchmarks*
 The benchmarks vary by county (regions); thus, the size of the bonuses varies by county
 Every year all the health plans taking part in Star rating program are required to submit their
bids (cost for providing services to their Medicare enrollees)
 Only plans with 4 or more Star ratings will be eligible for QBP (5%) (refer Fig. 1)
 Rebate payment varies from 50% to 70% based on the Star ratings by CMS (refer Fig. 2)
Fig. 1: Quality Bonus Payment by Star rating Fig. 2: Rebate Percentage by Star rating
Rating 2.5 3.0 3.5 4.0 4.5 5.0
Year
2014+ 50% 50% 65% 65% 70% 70%
Rating 2.5 3.0 3.5 4.0 4.5 5.0
Year
2015+ 0.0% 0.0% 0.0% 5.0% 5.0% 5.0%
Note: *Benchmark - the maximum amount Medicare will pay
the plan to provide Part C and Part D benefits in the county.

12. 12
CMS Star 2017 : Changes from 2016 Star Reporting
# Change Impact
1. Re-opening deadline from April 1, 2016 to May 1,
2016
Part C & D measures (C30, C31 and D03)
2. Removed exclusion for hospice stay Part D measure (D03)
3. Weightage changed from 1 (Process) to 1.5 (Access) Part C & D measure (C28 and D06)
4. Definition change for exclusion criteria Part C & D measures (C29 and D07)
5. C29 Removed measure from measure calculation Part C measures (C19)
6. C29 Added measures to measure calculation Part C measures (C01, C26, C30 and C32)
7. D07 Added measure to measure calculation Part D measures (D01, D03, D04 and D15)
8. Weights set to 0 (For contracts whose non-employer
service area only covers Puerto Rico)
Part D measures (D12, D13 and D14) for
summary and overall rating calculations
9. Addition of Categorical Adjustment Index (CAI)
adjustment methodology
Summary and overall rating calculations which
in turn impact the ratings of the plan
10. Changes in Star cut points of 40 measures of Part C
type
Impact the measure level calculations and
hence on the ratings of the contracted plans
11. Data display changes Will impact the UI for the measures C03, C20,
C21, C22, C23, C24, C25, C26, C28, D02, D04,
D06, D08, D09 and D10

13. 13
Impact on Health Plans (1/3)
Financial
 ACA established CMS’ Star ratings as the basis of Quality Bonus & Rebate Payments
 Rebate payments percentage depend on the Star rating of the health plan and are calculated as
the percentage difference between bid and benchmark
 Plans with 4 and more Star ratings will be eligible for quality bonus payment (QBP)
Enrollment
 Only 5-star Plans can market and enroll members throughout the year, others can do it only
during CMS specified enrollment period
 Starting 2015, CMS can terminate contracts of Low Performer Plans
 Medicare Plan Finder (MPF) does not allow users to enroll online in a low performing icon plan;
beneficiaries must contact the plans directly to enroll
 Notices are sent to beneficiaries in low performing icon plans explaining that they are eligible
for a special enrollment period to move to a higher quality plan
 CMS will terminate contracts that have failed to achieve a 3.0 Star rating for Part C or Part D for
three consecutive years
 Example: Contracts with less than a 3.0 Star rating for 2014, 2015 and 2016 were notified in
February 2016 that their contract would be terminated effective December 31, 2016

14. 14
Impact on Health Plans (2/3)
Competitive Advantage
 Medicare Plan Finder’s plan results sorted by lowest cost and highest quality; reducing the
visibility of lower rated plans
 CMS publishes Star ratings annually to help consumers compare Medicare Advantage and
Prescription Drug plans; lower ratings signifies lower performance and thus can reduce
enrollments
 The plans receiving bonus payments are required to use a part of the additional payment to
provide “extra benefits” for members
 Thus, the plans with higher quality ratings can provide a more attractive set of benefits than
their competitors, which may lead to higher enrollment in plans with higher quality ratings

15. 15
Impact on Health Plans (3/3)
Star Ratings on the Medicare Plan Finder (MPF)
 Medicare Plan Finder web tool helps Medicare beneficiaries to search and compare Medicare
health and drug plans in their areas
 Every year, CMS publishes Star ratings in the Medicare Plan finder to help beneficiaries in
comparing the health plans
 Also, Medicare Plan Finder sorts result based on Star rating of health plans
 From 2012, CMS began highlighting health plan with icons for contracts receiving lower
performance (rated less than 3 stars for at least the last 3 years in a row) and those receiving an
overall rating of 5 stars
Icon for High Performing Plan: Icon for Low Performing Plan:

16. 16
Recommendations and Best Practices
Higher Star Ratings determines two things for the plan contracts:
 Level of performance incentives it receives from CMS for Quality Delivery
 Perceived reputation – higher ratings will attract more consumers
In order to score higher Star ratings it is very important for the health plans to effectively and efficiently evaluate
their population. which can be achieved by leveraging healthcare IT like:
 Automating workflows like accommodating, integrating and aggregating data that health plans generate
from customer surveys, EHR etc.
 Capturing critical data elements from the clinical systems (EHR) as well as from the administrative claims
which will help in accurate and thorough HEDIS reporting
 Providing real-time actionable information to the end user such as gaps in care in order to timely and
effectively manage the population
 Identifying the members to prioritize with the help of configurable rules to close the gaps in care at
measure level which can have greatest impact on Star ratings with minimum efforts
 Improving member satisfaction by improving engagement with effective self-management such as by using
web-based and mobile tools that allow members to track their health, review the results of recent visits,
receive notification for upcoming visit etc.
Payers should collaborate with the providers to develop outcome-based models and value-based
reimbursement plans together which is in line with CMS reimbursement to payers

17. 17
References
 https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Bid-Pricing-Tools-
and-Instructions-Items/BPT2017.html
 https://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovGenIn/PerformanceData.html
 https://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovGenIn/Downloads/2017-Display-Measure-Data.zip
 https://www.medicare.gov/find-a-plan/questions/home.aspx
 https://www.medicare.gov/find-a-plan/results/planresults/plan-list.aspx

18. 18
Thank You
Authors:
Vivek Singh
Healthcare Business Analyst
thoughtleaders@citiustech.com
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