How Top-Ranked MA Plans Earn Their Stars

High-ranking health plans in the Medicare Advantage program share the strategies that have led to their success.

Garnering high marks in the Medicare Advantage five-star ratings program involves a complex set of factors that can change from one year to the next.

Health plan executives say the key drivers for achieving star ratings success are commitment to quality across their organizations and provider networks, sharing healthcare data in real time, and the ability to annually adapt to changes in how the plans are evaluated by the Centers for Medicare & Medicaid Services.

CarePlus Health Plans Inc., a subsidiary of Louisville, KY-based Humana, which offers MA coverage to thousands of seniors in Florida, is among 16 MA carriers that earned five-star ratings for 2015. David Jarboe, regional president of CarePlus, says a commitment to quality care is essential to achieving a high star rating.

"We believe our five-star achievement is due to our entire company's focus on achieving the best clinical and customer service possible, and improving each year," he says. It's an accomplishment that "couldn't have been achieved without our outstanding team of employees and the physicians who care for our members and partner with us to focus on preventive care and disease management."

Jarboe says successful MA health plans need to have a shared commitment to quality and attention to stars-rating metrics with their physician networks. "We work hand-in-hand with our physicians to actively educate and engage our members to improve their health outcomes," he says.

"We believe programs like our diabetic initiative, which encourages diabetic retinal exams, and our medication compliance and adherence outreach, have not only improved our star ratings but also and, more importantly, truly made a difference in the health and quality of life for our members."

Collaboration has been an essential element in boosting MA stars ratings at Franklin, TN-based Cigna-HealthSpring as well

"[We] made significant improvement with our 2015 star ratings, increasing our percent of membership in a four-star or higher plan from about 38% to 57%," the company said in a prepared statement.

"Our physician engagement model works collaboratively with both our network doctors and customers to align incentives and resources around quality health care results, which correlate directly with star rating measures. We've had the strongest results in markets where our networks are more engaged and aligned with our quality efforts."

Crossing the four-star threshold is a prime goal for all MA health plans because the high rating on the five-star scale makes insurance carriers eligible for quality bonus payments from CMS.

Portland, ME-based Martin's Point Generations LLC has earned a five-star MA rating in 2015, 2012 and 2010. Rebekah Dube, VP of senior products for Martin's Point, says a commitment to quality inside the organization and with all of its partners has been crucial.

"Across the organization, you have to have people working together," she says, noting that teamwork optimizes chronic disease management. "You have to have your physician network onboard, and you have to have your customer service people engaged."

Dube says high-quality customer service is both challenging and rewarding for MA health plans. "It's such a critical piece. We really value our relationship with our members and how they trust us," she said. "Every single interaction you have with a member is a moment to make an impact."

Martin's Point customer service representatives "have consistent, scripted conversations" with members, but the commitment to quality service does not stop there, Dube said. "We want to make sure you are getting the best care possible," she said, noting customer service representatives give members prevention tips and diplomatically inquire about whether members are in compliance with chronic condition care. "This isn't just about checking off a box for them."

CarePlus' Jarboe agrees that customer service is important. "The survey measures that assess member perception about a plan's performance are more subjective and are limited to a small sample of members, so that can be challenging. We have worked hard to improve customer service and believe that is a big factor in our becoming a five-star health plan," he said.

Tracking the Data
Dube, who has been an MA stars-rating program leader at Martin's Point for four years, says getting a real-time handle on healthcare utilization data is a make-or-break challenge.

"As the star-ratings program unfolded, what became very apparent was if you didn't have the data, you weren't going to achieve your full potential," she says.

But MA data provided to health plans by CMS is notoriously tardy. So Martin's Point developed its own ways to use real-time data to drive results. "We needed to be able to monitor ourselves. We worked with our data management team internally to build up our processes," Dube says.

Dube says Martin's Point has mastered tracking several data points in the NCQA's Healthcare Effectiveness Data and Information Set, particularly for key star-ratings metrics such as blood sugar management, blood pressure control and process measures such as compliance with testing schedules.

Pharmacy data has been a thorny area for MA health plans, she said. "CMS provides tracking and trending pharmacy data, but there's a lag there," Dube says. "We've built our own processes to follow member compliance on medication."

Moving Metrics

One obstacle common to all government-sponsored business lines is adapting to regulatory changes.

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"Each year, CMS challenges health plans by changing some of the targets of measure that are used to determine star ratings. We will have to continue to improve our performance year-after-year in order to maintain our current five-star rating," Jarboe says.

"In general, we work to improve all areas and dedicate resources to improve ourselves each year. Quality improvement is a mindset that requires constant oversight to improve and maintain what we have achieved."

Dube says MA health plans must have flexibility ingrained in their business culture.

"It's not standing back and saying, 'No, we can't do that.' It's taking a problem-solving approach," she said. "We know that this business is rapidly changing, and that's not going to stop. Grounding our team in that mentality is really important."