LARGE U.S. HEALTH PLAN:CMS STARS DATA QUALITYANALYSIS AND MEDICARE

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The Centers for Medicare and Medicaid Services (CMS) developed the Star Quality Program to measure and report to consumers on Medicare Advantage plans’ abilities to drive quality and high levels of service, and to promote improvements across the board for these quality and service metrics. In some states, Medicaid payers like this health plan are required to offer a Medicare Advantage product to qualify for the Medicaid business. This means that if this health plan fails to earn a sufficiently high Star Rating for its Medicare Advantage business, its Medicaid business in that state is also potentially at risk.

The Star Rating Program rates each plan from one to five Stars across 50+ metrics. Plans scoring less than three Stars receive CMS Low Performing Plan Status and risk

In 2014, this large, multistate health plan asked Accenture to develop a strategy to help improve its performance in the CMS Stars Program. Working with Accenture, this health plan achieved significant performance improvements in its Stars performance The plan continues to use Accenture’s Stars Optimizer tool to identify and drive further improvements.

This multi-region US health plan had Medicaid contracts in 19 states with Medicare Advantage plans in six of those states. The plan had 3.2 million total members, including more than 8,000 members eligible for both Medicaid and Medicare. Significant near-term growth was anticipated in this dual eligible membership population.

loss of their Medicare business, as consumers are more likely to purchase plans with higher Star ratings. In addition, CMS pays bonuses only to those plans achieving Star Ratings of four Stars or higher. The timeline for plans to improve their performance is short relative to the length of CMS’s payout cycle, so plans like this specific health plan must drive performance enhancements in the near term, in anticipation of future CMS Star ratings and bonus payouts.

This health plan anticipated significant growth in its Medicare/Medicaid dual eligible membership and sought Accenture’s assistance to revamp its strategy for improving its performance in the Stars Program as part of its efforts to scale its business.

OPPORTUNITY

OVERVIEW CLIENT PROFILE

Accenture helped this health plan develop a multi-phased program to help update its Stars strategy and performance, leveraging Accenture’s prior insights with the CMS stars program as well as Accenture’s operational preferred practices. Accenture helped with the following:

ASSESSMENT of the current state of the health plan’s performance in the Stars program, analyzing its 2013 Stars scores.

IDENTIFICATION and execution of a series of quick-hit improvement opportunities.

EMPLOYED Accenture’s Stars Optimizer Analytics Tool to organize measures for operations management and to help drive governance priorities across the health plan’s contracts, along with identifying owners for each measure and developing improvement action plans.

DEVELOPMENT of targeted and evolved business priorities, information management principles, analytics and data governance into an actionable strategy.

PROPOSED establishment of the infrastructure and processes for data governance and analytics, to ensure the ongoing success of the health plan’s Stars strategy.

DEVELOPED an investment scenario analytics capability to help assess the return on investment for individual measures, allowing this organization to better compare the cost of investing in specific measures with the estimated Medicare Stars bonus payouts resulting from higher Star ratings.

SOLUTION

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RESULTS

The elapsed time from the measurement of plan performance by CMS to ratings and bonus payouts is nearly two years. Despite this long lead time, the health plan saw early improvements in its plans’ ratings, with incremental increases ranging from one-half Star to one full Star, a significant improvement in performance. The health plan also saw across the board improvements in specific Star Program measures, including a 25-50% increase in medication adherence in health plans in six different locations.

The health plan’s early results indicate it is on a positive trajectory with its Star Program performance. The organization continues to employ Accenture’s Stars Optimizer tool to help identify and execute on ways of improving its performance in the Stars Program. With this capability, this large health plan is better able to identify and prioritize Stars measures that may require attention, target its improvement efforts at those measures and instil a culture of continuous improvement within its organization.

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