Introduction

The National Committee for Quality Assurance (NCQA) Health Plan Ratings and Centers for Medicare & Medicaid Services (CMS) Star Ratings each serve as highly influential measures of health plan quality performance nationwide. These ratings serve as meaningful indicators of how well plans deliver high-quality, patient-centered care, providing consumers, employers, and policymakers with a standardized way to compare plans. However, these ratings are more than reputational for health plans – they directly impact financial performance, enrollment growth, and contracting. Specifically, CMS Star Ratings are tied to Quality Bonus Payments and impact plan rebates and member premiums for Medicare Advantage (MA) plans, while NCQA ratings influence market competitiveness across all lines of business.

Health plans seeking to improve performance and increase next year’s NCQA & CMS Star Ratings must begin to strategize for success today. This begins with a clear understanding of how each rating is calculated, key drivers of current performance, and the resources required to identify and act on gaps in care with targeted quality improvement initiatives.

With a comprehensive strategy and targeted interventions, health plans’ quality improvement efforts can not only improve patient outcomes, but also boost financial performance, strengthen provider relationships, and drive growth in enrollment.

5 Steps to Improve Your Rating

The following 5 steps can provide a structured framework to improve health plan performance, driving an increase in your plan’s Star Rating:

1. Assess Current Performance

Break down your performance to identify which specific measures are pulling down the overall rating most. Identify all measures below 4 stars, and rank the measures from lowest to highest, evaluating the relative difficulty to improve each measure.

Consider:

• What underlying patterns or missed opportunities may have contributed to underperformance?
• What might be quick wins vs. long-term improvement opportunities to address this underperformance?

2. Prioritize The Right Measures

Determine which measures should be prioritized to ensure resources are deployed where they’ll have the greatest impact. Some measures can be improved with targeted interventions, while others may require broader, systemic change.

Consider:

• How many HEDIS measures are needed to achieve the next highest rating?
  • Develop a model that allows you to manipulate measure results until you achieve at least 4 stars.
• Which measures are closest to the nearest cut point?
  • Calculate the difference between the current result and the 75th & 90th percentile benchmarks. Rank order the measures by putting those measures closest to the 75th & 90th percentiles at the top of the list.
• Which measures are triple-weighted, increasing impact if the next cut point is achieved?
  • Based on above results, focus on measures that are triple-weighted first, followed by the remaining measures in the 75th & 90th percentiles.
• Which members’ care gaps require proactive outreach and engagement, and which are likely to be closed by the members themselves throughout the year?
  • Determine how to prioritize member chase lists to maximize impact and efficiency of staff resources.

3. Identify Barriers

Evaluate the root causes behind underperformance (e.g., provider engagement, member engagement, care coordination, access to care).

Consider:

• Do your providers have the necessary data and reporting to identify patients’ care gaps?
  • Support providers with monthly open Care Gap patients lists.
  • Monitor improvement monthly and create Corrective Action Plans (CAPs) for providers that don’t improve after several months.
• Are patients being lost to follow-up during transitions of care?
  • Are appointments made prior to discharge to the patient’s PCP?
  • Are follow-up calls made to patients after scheduled PCP appointments to ensure patients kept their appointments?
• Are access and scheduling challenges impacting member engagement?
  • For example, if Mammography scores are poor, is it due to limited availability of mammography centers in the geography? If so, consider contracting with additional sites.

4. Design Targeted Interventions

Develop tailored initiatives to address identified barriers. Deploy resources strategically to maximize impact on patient outcomes and overall health plan performance.

Consider:

• Which patients have the highest number of open care gaps?
  • Are these patients associated with the same PCP? If so, provide the PCP with education on Clinical Practice Guidelines and their impact on patient outcomes. If not, broader education across the network may be required.
• Do you have the staff required for both in-person and telephonic outreach and engagement of these members?
  • Determine the number of patients that need outreach and compare against current staff capacity.
• Do you have the ability to follow up with patients and close the loop on care gaps?
  • Set up a patient outreach call center to remind patients of their upcoming PCP appointments, following up within 2 days of the appointment to ensure it was kept, and to reschedule if not.
  • Integrated within each practice, provide staff with daily member chase lists, deploy care navigators for outreach to members not enrolled in care management, and develop clear workflows for standardized documentation and reporting of outreach and gap closure activities.

5. Measure, Manage, and Adapt

Continuously track and monitor progress on care gap closure and performance across Key Performance Indicators (KPIs) tied to relevant measures. If an initiative isn’t leading to improvement, recalibrate and consider a new approach.

Consider:

• Do you have standard dashboards and reporting with actionable insights to monitor performance on a regular cadence?
  • Establish a monthly performance dashboard to track each measure’s progress over time against benchmarks with both leading and lagging indicators.
• Are providers equipped with the right data and tools to drive improvement at the point of care?
  • Integrated with EHR data, develop provider- and practice-level scorecards to allow real-time visibility into open care gaps and better engage providers in the co-development of gap closure and performance improvement strategies.
• Do you have the appropriate internal and external data to measure and manage performance?
  • Combine claims, EHR, and supplemental data to ensure performance is being tracked accurately and validate data completeness for submission to CMS and/or NCQA.
• Do you have a clear accountability structure to drive performance management?
  • Identify and assign ownership for metric performance and formalize feedback loops for continuous improvement.

How COPE Health Solutions Can Help

Improving your health plan’s Star Rating requires data-driven insights, provider alignment, and sustainable strategies for continuous improvement. COPE Health Solutions partners with plans nationwide to design and implement programs that deliver measurable improvements in quality and patient experience, driving an increase in Star Ratings.

Additionally, COPE Health Solutions has earned the Certified Data Partner designation as a part of the NCQA Data Aggregator Validation Program, indicating our firm’s commitment to meeting the NCQA’s rigorous standards for data accuracy, completeness, and reliability.

Our proven approach is centered around:

• Data Analytics:
  • Determining which measures to prioritize based on overall rating impact, weighting, and proximity to the nearest cut point.
  • Developing care gap reports for providers, identifying low-performing providers.
• Provider Engagement:
  • Deploying provider outreach teams, sharing care gap reports with low-performing providers.
  • Monitoring trends in improvement by provider, with accountability driven by transparent reporting and leadership oversight.
• Member Engagement:
  • Deploying patient outreach teams, targeting patients with the highest number of open care gaps for initial outreach calls and appointment scheduling.
  • Standardizing best practices such as appointment reminders and follow-up calls to strengthen member engagement, patient satisfaction, and care coordination.
• Continuous Performance Monitoring:
  • Developing standardized dashboards and reporting for frequent and transparent evaluation of performance.
  • Building feedback loops to support continuous improvement.

Looking to improve your health plan’s performance? COPE Health Solutions will provide your organization with deep expertise in quality improvement and population health management to strengthen performance, improve outcomes, and build stronger relationships with both providers and members. To learn more, contact us at info@copehealthsolutions.com.