5 Strategies for 5 Stars: Cigna’s Approach to CMS Star Ratings

August 16, 2019 - Achieving five stars in all three domains – Medicare Advantage, Part D, and overall - is difficult. The work of Cigna’s HealthSpring of Florida plan in 2018 earned them five-stars across the board, making them one of only two health plans to do so.

“As you might imagine, we’re super proud of that. To get all three is rare, so it’s pretty exciting,” Cigna Medicare Advantage Vice President of Stars David Meyer told HealthPayerIntelligence.com.

Each year the Centers for Medicare and Medicaid Services (CMS) releases star ratings for health plans, a measure of a plan’s quality of care. The CMS Five-Star Quality Rating System allows consumers to compare plans based on their performance and beneficiary reviews.

The star ratings system began in 2007 as a way for CMS and consumers to compare health plans on metrics other than cost. Star Ratings are reported for individual components of each plan (i.e. Medicare Advantage and Part D), and an overall quality score combines these metrics for a comprehensive measure of a plan’s performance. A five-star rating indicates that a health plan that delivers quality care and has high beneficiary satisfaction.

Improving star ratings can be difficult as each year CMS develops cut-points based on the performance of all plans for each measure over the previous year. Maintaining performance year after year is not enough to sustain a high star rating. As all health plans improve their quality, the distribution of scores shifts toward a more high-performing end. Therefore, it becomes increasingly harder for a plan to move from four to five stars because the threshold is also rising.

Cigna focused on “incremental sustainable wins” to help improve its star rating.

“We think it’s the right thing to do for a long-term impact on customers,” Meyer added.  “We also think it’s the right strategy to not chase individual measures and individual cut points but to have a much more holistic approach.”

The star rating score is the product of over forty metrics across over ten datasets. CMS independently evaluates the data for each health plan, but plans should implement best practices to help improve these scores.

A dedicated team should focus on organizational change that helps improve a plan’s star rating but also the quality of care delivered to beneficiaries. Rather than chasing specific measures, payers should focus on improving overall quality of care through customer service and provider support to help improve the ratings of their plans.

Communicate with Beneficiaries  

Beneficiaries are not always aware of the abundance of services available to them through their health plan. The ability to improve their health could be at a beneficiary’s fingertips and they don’t know it.

“Our experience is that customers want to be healthy. They don’t wake up in the morning wanting to be unhealthy,” said Meyer, who oversees Cigna’s operations, analytics, and reporting related to stars. “To the degree you can reduce clutter and provide a clear and concise message in your communications, that’s differentiating.”

Meyer explained that Cigna’s communications range from newsletters to recall programs that provide customers with streamlined but comprehensive information about available products and services.

“You’re trying to make sure that people understand the importance of timing, what they should be doing during different times of the year. It’s more than just one or two interactions. It’s comprehensive,” he added.

Understanding the resources available to them will help beneficiaries more readily utilize these resources and ultimately improve their health. 

Listen to the Beneficiary’s Voice

CMS Star Ratings were designed to represent a beneficiary’s experience with the health plan. A majority of the star rating measures are patient-reported information on the quality of the plan. Several datasets used to determine a star rating rely solely on a patient’s perception of care.

Listening to beneficiaries and taking their advice into consideration year over year can help a health plan improve beneficiary satisfaction with the plan and ultimately their star rating.

“It’s impossible to serve your customers if you don’t listen to their voice. The voice of the customer is a phrase you hear a lot, but everyone doesn’t take it as seriously as they could. One of the things that we’ve done particularly well at Cigna is investing in the voice of the customer,” stated Meyer.

Understanding what’s driving beneficiaries to feel the way they do enables a plan to more readily tackle complaints and grievances.

An independent reviewer assesses how a plan handles appeals, but plans that focus on customer service will see a trickledown effect to a higher star rating. A friendly call center staff that is well trained will help ensure timely and standardized responses that keep beneficiaries (and the independent reviewer) happy. 

Incremental Outreach

Many of the CMS Star Rating measures focus on prevention and coordinated care, but non-compliance is often an issue.

Plans should focus on strategies for eliminating the barriers beneficiaries face in receiving these treatments. Emphasizing how important preventive care and care coordination are across a health plan will have a knock-on effect on star ratings.

Meyer highlighted Part D measures as an example. “They are proxy measures for the customer taking medication, but they’re really focused on customers’ access to medication. Did they purchase it? Do they physically have the medication in their possession?”

Cigna implemented an outreach program to provide beneficiaries with a home delivery service for their medications. Over 85 percent of the plan’s members benefited from this program. Delivering medication directly to beneficiaries eliminated access as a barrier.

“It’s not that customers couldn’t get the medication in other ways, but what we’re doing is we’re taking a barrier to compliance off the table,” Meyer explained. “We’re making sure that customers have the medication they need physically in their residence so that they’re more likely not only to have possession of it but to actually take the drug.”

With home medication distribution rates so high, Meyer said things flowed from there. “The proxy measures started to take care of themselves.”

Incrementally improving pilot programs, such as Cigna’s home medication delivery system, will allow for the long-term success of this star measure. An important subsequent step is integrating the core of what the measure is trying to estimate into Cigna’s care delivery rather than treating the program as a one-off. This focus on the bigger picture is instrumental to long-term success with star ratings.

HEDIS Measures

The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the National Committee for Quality Assurance (NCQA) to measure how well a plan is managing the health of their beneficiaries both in terms of preventive care such as screening tests and vaccines as well as managing chronic conditions.

Measures included for star ratings range from breast cancer screening to rheumatoid arthritis management.

HEDIS is the most abundantly used data source for Star Ratings, so ensuring its accuracy will help minimize time spent on data collection. Supporting providers and staff to close gaps in care and focus on prevention through care coordination and follow up can improve an overall Star Rating.

CAHPS Scores

Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a tool developed by the Agency for Healthcare Research and Quality to examine the plan’s communication skills and accessibility of its care/resources from a patient perspective.

The survey asks beneficiaries about their experience with the health plan. Measures used for Star Rating include obtaining appointments and care quickly, customer service, and overall rating of a health plan.  Focusing on timely and friendly care will help to improve CAHPS Scores for CMS Star Rating.

HOS Measures

The Health Outcomes Survey (HOS) gathers data on the health status of the Medicare population with the goal of understanding beneficiaries’ perceptions of their health status.

HOS measures used for CMS Star Rating fall into two categories: functional status and hybrid HEDIS measures. The functional status questions ask a patient if she is improving or maintaining her physical and mental health. Hybrid HEDIS measures use HOS data to supplement HEDIS measures focused on physical activity, bladder control, and falling risk.

Research has shown that HOS patient-reported health status measures are associated with clinical outcomes such as readmission rates. Improving patient-reported health status could impact not just that specific CMS Star measure but others as well.

Prescription Drug Event Data

Prescription Drug Event (PDE) data is most heavily used for Part D Star Ratings. If a health plan covers both Part C and Part D, PDE data impacts a plan’s overall rating as well.

The data is similar to HEDIS in that it is administrative and standardized, but PDE data is a summary record of a plan’s prescription record rather than individual claims. Event data incorporates post-transaction adjustments between the plan, pharmacy, enrollee, and CMS. These records only account for paid claims, so unpaid prescriptions will not appear in the data.

PDE measures used for CMS Star Ratings typically reflect a plan’s ability to help beneficiaries adhere to medications, so a focus on adherence can help improve a plan’s Star Rating efficiently.

Other Data

Several other data sources are used to calculate the remaining CMS Star Rating measures but are only used for a handful of measures.

For example, the Complaints Tracking Module (CTM) monitors complaints beneficiaries or providers report to CMS about a health plan. An Independent Review Entity (IRE) will call a health plan to examine how the plan handles appeals. This review is incorporated into several CMS Star Rating, so a focus on customer service and timely resolution of problems will help improve these final measures.

Support Providers

Health plans often critique the CMS Five-Star Quality Rating System for using measures that are more reliant on clinical care than activities on the part of the health plan itself. For example, a plan does not necessarily have control over a provider’s decision to order a screening test for a patient.

Plans must figure out how to encourage providers to perform the tasks involved in star ratings measures without introducing additional burden. 

“If you start out with ‘doctors are busy’ as your truism, then the next question is ‘what does help mean when I’m interacting with somebody that’s so very busy?’” Meyer explained. “For us, it’s that focus on only asking for something where there is a true need that can be demonstrated.”

Meyer said health plans need to be sensitive about their demands on providers because of concerns about the latter’s workflow. Asking about fifteen beneficiaries may not seem like a big ask for a health plan, but to the provider, this task can prove disruptive to all the other tasks he must do.  

“We don’t want to ask for a lot. When we ask for something, we want it to be truly meaningful. Then, we tie the loop back later and explain how it was meaningful as much as possible so that people get a sense that you didn’t ask for something that wasn’t critical,” he noted.

Meaningful provider engagement promotes a philosophy of mutual respect that can make a difference at the end of the year when plans need providers to help close care gaps.

“Many physicians have eight, ten, or twelve health plans that they’re dealing with. You truly have to try on a daily basis to interact with physicians with respect. It can be the difference between your request getting prioritized over that of another plan,” Meyer shared.

“If physicians believe that you’re trying to holistically help their entire beneficiary ship, you’re only going to get three more patients,” Meyer said. “Fundamentally, clinicians want to be in the business of providing the best quality care for all their patients and they want their health plan partners to have the same attitude.”

Support Office Staff

The office staff is another crucial piece for plans to succeed at star ratings. Staff can help close gaps in care by following up with patients, recording data accurately so plans do not need to review medical charts to gather information, and promoting a positive experience for beneficiaries.  

“Office staff really need a separate communication, one that’s focused on them and their needs,” stated Meyer. “It’s the same type of keeping the faith, but it means something different to different staff within the office.”

While HEDIS and PDE data are systematically recorded through claims and prescriptions, there is often missing data that requires time and resources to collect. Missing data means star rating measures might not accurately report the care being given.

For example, information not collected from claims data on a specific HEDIS measure must be pulled from patients' medical records. Health plan employees must then reach out to providers and ask for medical charts to review. Sending medical records to health plans can be a timely process as protecting patient data is of the utmost importance.

Supporting staff in proper documentation and follow-up in the same mutually respectful manner Meyer recommends plans treat providers will help reduce missing data and ease the process of data collection. A health plan that supports staff will see this reflected in its star rating. 

Think Big Picture

Each year, CMS updates the measures that are incorporated into the CMS Five-Star Quality Rating System to more accurately reflect the most up-to-date data and outcomes available. Focusing on a limited number of measures is tantamount to attempting to predict the future.

“If you’re performing really well, there’s an expectation that you’re going to continue to perform well and you have to put a lot of crystal ball time in on where do you think things will go,” Meyer said.

Trying to move a measure by a few points is not the best strategy for improving a health plan’s star rating.

“You don’t go in tactically thinking a certain measure is going to be three points higher or the cut points are going to move three points. You don’t have those conversations. You focus on the fundamental thing that the measures are trying to go after,” Meyer noted.

Improving a plan’s star rating can seem like an insurmountable mountain to climb. There are many datasets to juggle and measures change every year, both challenging plans to determine where they should focus.

Because the cut points for star ratings change each year, success one year does not necessarily mean success in the following one.

“You have to be humble,” Meyer stated. “You have to try things, be open to things that don’t seem like they would have an impact or would work and allow customers to give you feedback. “

An understanding of the goals of specific measures will help a plan focus more on big-picture quality improvement rather than getting bogged down in individual measures. Understanding the crux of each dataset used to generate a star rating will allow plans to focus on big-picture changes that will improve a variety of measures rather than being stuck on one. 

“When you consider what Cigna has been able to accomplish in Florida with our provider partners, it’s really a story of incremental sustainable wins. Not everybody approaches stars that way, but we think that’s the secret sauce,” Meyer concluded.