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Boosting Stars: Predicting Medicare Advantage HEI scores

The Centers for Medicare and Medicaid Services (CMS) is changing the Stars reward program to incorporate Health Equity Index (HEI) scores. Is your health plan organization aware of HEI score implications to your current Star Rating? Press Ganey can give you an early look at how the score will affect your ratings.

Health Equity Index: A new Stars landscape

Several big changes are coming to the Medicare Advantage Stars program. The 2024 Final Rule from CMS introduces a new HEI Reward Factor for the 2027 Star Ratings, replacing the current Reward Factor. This change, along with others, puts the achievement of plan quality bonus payments at serious risk. Historically, the Reward Factor focused on reducing variation across Stars measurements and rewarded plans with low variation or consistently high performance. Many health plans have used this scoring bonus to elevate their Star Rating to a level that meets the criteria for receiving a quality bonus payment (4 Stars or more).

The new HEI Reward Factor from CMS encourages health plans to prioritize reducing healthcare disparities for members with social risk factors (SRFs). CMS has chosen to use risk factors associated with SRFs—e.g., Low-Income Subsidy (LIS), dually eligible for Medicare and Medicaid, and those who qualify for Medicare due to a disability to evaluate plan performance for a subset of Star measures. CMS indicated they will likely introduce additional social risk factors (e.g., race and ethnicity) as the ability to identify and measure risk factors improves.

The initial rollout of the HEI Reward Factor includes a mix of HEDIS and HOS measures, along with eight CAHPS survey Star measures:

  • Getting needed care
  • Getting appointments and care quickly
  • Customer service
  • Rating of healthcare quality
  • Rating of health plan
  • Care coordination
  • Rating of drug plan
  • Getting needed prescription drugs

CMS will review health plan Medicare Advantage contract-level performance on each of these measures segmented by SRFs, dually eligible, and disabled members and score plans based on how they rank against others. CAHPS measures will have a significant impact on the overall HEI Reward Factor, as these measures have higher weightings in the Stars program, and those weightings carry over to the HEI Reward Factor calculations.

CMS published contract-level reporting via their Health Plan Management System (HPMS), which allows plans to compare their CAHPS performance for members with SRFs against those without SFRs, and indicated within the report how payers separated plan performance into three buckets:

  1. Plans that perform in the bottom third received -1 point.
  2. Plans that performed in the middle third received 0 points.
  3. Plans that performed in the top third received +1 point.

Press Ganey’s solution for health plan Star Ratings

Working with several health plans, Press Ganey has been able to replicate the calculations CMS utilized to create these stratified reports, and will be able to calculate the stratified reporting at the end of the CAHPS reporting period. This is significant for plans: It will help them identify which CAHPS Stars measures are driving middle- and lower-tier scores. Plans can access this report today to target specific CAHPS measures.

Press Ganey HEI Analysis customers can view HEI performance scores before the results are published by CMS because of unique data access. 

Press Ganey can then help further segment a plan’s CAHPS eligible membership based on predictive analytics to identify those members within each targeted CAHPS measure who are likely to rate the plan less than positive, have at least one social risk factor, and are likely to complete the CAHPS survey if it’s sent to them via email or traditional mail. This timely, member-specific reporting helps health plans reach out directly to a small subset of members. And this allows plans to solve problems, improve access to care, and further educate members about their plan benefits. Plans that have used this approach have improved and sustained CAHPS measure performance and Star Ratings.

Health Equity Index (HEI): Maximize additional points toward Star Ratings

HEI reward estimate, delivered 2–3 months before CMS publication

  • Reverse-engineered HEI Reward Factor calculation from CMS.
  • Industry-leading book of business allows us to create HEI population means and benchmarks.

Targeted benchmarks for specific opportunities

  • CMS publishes composite measure-level cut-points; we calculate them at the individual-item level.
  • HEI group is comprised of three SRF groups: dual eligible, low-income status, and disabled. Press Ganey can benchmark each specific group.  

Prescriptive playbook for maximizing reward for each individual contract

  • Contract A:
    • Dual eligible: Getting needed care right away
    • Disabled: Access to specialist 
    • Projected reward increase: +0.12 
  • Contract B:
    • Increase HEI population by 2%
    • Low-income status: Routine care
    • Projected reward increase: +0.18

Reach out to a Press Ganey health plan expert to get a better understanding of how this change will affect you—and how Press Ganey’s solution can help you optimize your HEI Reward Factor.  

About the author

David L. Larsen currently works as Senior Advisor Member Experience at Press Ganey and prior to that he worked as an independent healthcare consultant working with predictive analytics, member engagement, and pharma vendors to improve their offerings and sales approach to managed care plans and working with managed care plans to improve their Medicare Advantage Star Ratings focusing on improvements related to CAHPS, HOS, HEDIS, medication adherence, and member experience measures. David served as the Director of Quality Improvement for SelectHealth in Salt La­ke City, Utah for 32 years and worked for Intermountain Healthcare for 38 years. SelectHealth is a mixed model HMO with more than 950,000 members in Utah, Idaho, and Nevada across all insurance product lines including, Medicare Advantage, manage Medicaid, large, small, and individual commercial plans, and ACA plans. Intermountain Healthcare is an integrated health care delivery system with 23 hospitals and over 1,500 employed physicians. As the Director of Quality Improvement, David had responsibilities for oversight of the Medicare Advantage Stars program for which SelectHealth received a 5 Star rating in 2022, maintaining NCQA accreditation; HEDIS performance measurement and improvement; CAHPS and HOS measurement and improvement, public reporting (transparency), and population health. David has also been responsible for the oversight and development of chronic disease registries, performance measurement and web based reporting systems, quality improvement pay for performance incentives for providers, provider transparency programs, and direct patient improvement interventions related to chronic illnesses including patient adherence monitoring, reminders, and incentive programs.

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