The plan received a 2.5 Star Rating in SY23 and was forecasted to receive a 2.5 Star Rating again in SY24, due in part to Tukey outlier deletion impacts as well as underperforming CAHPS/HEDIS measures. Underperformance not only caused the plan to miss millions of dollars of revenue from Quality Bonus Rating and rebate bonuses, but also put it at risk of contract termination by CMS.
To avoid the risk of contract termination and a desire to get back in the rebate/QBP zone, the plan required immediate Stars program support to chart a path to improved operational performance and increased Star ratings.
The team conducted an 8-week rapid assessment built on stakeholder interviews, deep Stars knowledge and algorithmic based data analysis. Solutioning was oriented around redefining roles and responsibilities and creating governance oversight to drive awareness and accountability across the program. We leveraged data insights to identify measures with the greatest impact to overall performance and created measure-specific interventions accordingly.
A major facet of our recommendation was the overhaul of the HEDIS/Chart Chase season, with improved governance and reporting capabilities to better direct resources and maximize performance. Secondly, we managed the delivery of member outreach campaigns, targeted to specific populations of need and strategically positioned throughout the year.
Finally, our team delivered a Stars Transformation playbook summarizing key findings and recommendation charters detailing next steps and milestones. We implemented our recommended solutions across multiple Stars domains, prioritizing HEDIS and CAHPS, stood up effective governance practices and facilitated realistic measure level goal setting to support execution and enable performance improvement.
Between SY23 and SY24, the contract improved from 2.5 to 3.5 Stars and mitigated the risk of contract termination by CMS. This improvement was defined by achieving 5 Stars in parts C & D QI, improving: 16 measures, 78% of CAHPS rates and 100% of eligible HEDIS/Hybrid rates. The client’s performance landed in the top 10% of plans for SY24.
The client is a for-profit managed care SNP insurer that coordinates delivery for >10,000 lives receiving both Medicare and Medicaid coverage. Based in the Northeast, this wholly owned subsidiary focuses on delivery through local, regional and community-based resources.