A Deeper Dive into CMS’ Simulated Cut Points and Potential Impacts to Four Star Strategy

As I continuing to dig into CMS’ Star Year 2023 simulated cutpoints I see much larger than anticipated increases in some of the measures that matter most to star goal attainment. In this article, I highlight measure cut point increases that stood out to me and that may prove challenging to compensate for.

On a positive note, at least we now know that non-CAHPS measure cut points cannot move more than 5% bidirectionally from the Star Year 2023 simulated cutpoints provided by CMS. This will help with the accuracy of star year 2024 projections and will help plans set HEDIS MRR targets and related measure priorities. Plans will now have a better idea of how much is riding on their ability to improve CAHPS and call center (FLL/TTY) measure performance in Q1 of 2023.

Colorectal cancer screening increased at every level, with the most notable jumps at the two and three star cutpoint thresholds. If you do not currently have in-home FOBT/FIT kits as a part of your star’s strategy, you may want to consider doing so. Partnerships with key, high-volume providers are often most effective with earlier, more frequent and higher-touch outreach to members that finished 2023 non-compliant.

MTM program Completion Rate for CMR also increased at every cutpoint level with a whopping 21 point jump to the right at the two star threshold and another 11 point jump at the three star threshold. If you have not done so already, reexamine related measure goals and KPIs in your MTM vendor contracts and have your vendor explain to you what they are going to do differently in 2023 to compensate. Plans may want to consider a hybrid approach to gap closure, where harder to reach and higher-need populations are kept in-house and assigned to health plan pharmacists and/or pharmacy students for CMR completion.

?The Care of older adult medication review and pain assessment measures also shifted to right at every level, but most notably at the 2 and 3 star thresholds. The 2 star threshold for COA med review increased by 30 percentage points. To earn a 5 star in this measure a plan would now need to move 96% of the eligible population to numerator compliance. The large delta between the 2 and the 5 star thresholds may more reflect the ease of a plan’s ability to access medical record documentation than true care delivery. Regardless, if data access, capture and exchange are barriers for your health plan, pursue and encourage investments that improve bidirectional data sharing capabilities, leaning into strategic partnerships with high volume providers. Success in many of the new and returning star year 2023 measures, like transition of care management, follow up after ER use for pts with multiple chronic conditions and plan all cause readmissions) is also tied to timely and robust data sharing.

Encourage providers to Incorporate a standardized template to capture needed COA measure documentation for members 66 years of age and older, and don’t forget COA functional status assessment (a returning measure) in your planning.

High performance in the triple weighted HEDIS measures, blood pressure & blood sugar control, are essential to overall star ratings goal attainment. Plans that used to eek by with 3 stars and a rate of 62% in the blood sugar control measure must now achieve a minimum of 72% just to maintain. Lack of improvement would result in dropping two whole star levels in this challenging intermediate-outcomes measure!

Innovative (not check the box) disease management programs that tie incentive dollars to program completion, robust care management strategies, meaningful provider partnerships, carful coordination of medication adherence and related HEDIS measures and a tight HEDIS data capture programs are a few vital, strategies necessary for 4 and 5 star attainment.

Several studies have suggested that adults face an increased risk of diabetes diagnosis after contracting COVID-19 and we have all read scholarly articles about Diabetes and COVID-19 having a significant effect on populations adversely affected by health inequalities. Health plans must all have a process for stratifying members based on social risk factors and tailoring interventions to meet the unique needs of underserved subsets. Ability to improve blood sugar and blood pressure control measure rates for these subsets will not only yield immediate star rating results but will also pave the way to future star’s program success when CMS replaces the r-factor with the Health Equity Index (HEI) methodology! ?

Perhaps most alarming to me, were the seismic shifts to the right at all cutpoint thresholds for most health plan operational measures. These measures comprise about 25% of the star ratings measure schema and were easy wins for most health plans, often compensating for poor performance in harder to move CAHPS, intermediate-outcomes, and outcomes measures.

For example, plans that scored 75% and achieved 3 stars in the Part C appeals timeliness measure in Star Year 2023 now need to improve to a minimum rate of 93% just to maintain their average rating. The 4 star cutpoint threshold moved up 12 percentage points, and the 5 star cutpoint threshold jumped from 97% to 100% leaving, literally, no room for error!

I was surprised by the extent to which most health plans benefited from the inclusion of low end outliers in the call center TTY/FLL measure cut point calculations. CMS’ SY 2023 simulation data shows 40 and 38 percent increases at the 2 star thresholds for Part C & D TTY/FLL call center measures, respectively. They jump to the right again by 23 and 17 percent at the 3 star threshold and by another 6 and 11 percent at 4 stars. The Part D call center measure takes an additional 6 percent shift to the right at the 5 star threshold.

Success in these measures rely heavily on continuous and persistent training, tracking, monitoring & oversight and on well established, well-socialized pathways for escalation and issue mitigation with those taking calls, FLL vendors and internal IT leaders.

As we saw in the recently Proposed rule, this is only beginning. Proposals to move the 'hold-harmless' provision (for the 5 X weighted quality improvement (QI) measures) to the five star level, to remove cutpoint guardrails, and to incorporate behavioral health into stars (via the addition of opioid overuse & poly-pharmacy measures), among other programmatic changes, all promise to make 4+ stars attainable only for truly exceptional plans.

I encourage you all to continue sounding the alarm with leadership about current and upcoming star rating changes, and the unique impacts they will have on your plan, to ensure you receive the funding, prioritization, resources, and staffing needed to hit goal. If internal knowledge or resources are limited, there are several capable and knowledgeable vendor partners out there with successful track records. I have been working in Stars for years and would be happy to introduce you to some of my favorites and am open to bidirectional sharing of information and strategies that could help us both succeed.

Happy New Year and Cheers to being a truly exceptional health plan in 2023 and beyond!!?