CMS Star Ratings Program: A Look Into Recent Changes & How To Prepare

CMS Star Ratings Program: A Look Into Recent Changes & How To Prepare

In February, the Centers for Medicare and Medicaid Services (CMS) released Part II of its 2021 Medicare Advantage and Part D Advance Notice, and the Medicare Advantage and Part D Program Technical Changes proposed rule, which included several updates to the Medicare Advantage Star Rating program. The CMS Star Rating program is used to evaluate the quality of patient care and experience for Medicare beneficiaries, and rates health plans using a five-star system based on their performance against 30+ quality measures, including both clinical HEDIS measures, and survey measures.

Beginning in measurement year 2021, which will impact health plans’ 2023 Star ratings, two additional HEDIS measures will be included for scoring; Transitions of Care and Follow-up after ED Visit for People with Multiple Chronic Conditions. Both measures will be worth one point of health plans’ performances in the Managing Chronic (Long-Term) Conditions domain and will impact their overall ratings on the five-star quality scale. With these new measures, and especially as the Transitions of Care measure is expected to be weighted more heavily in the future, it’s critical that health plans have the tools and resources needed to efficiently monitor members’ care transitions and ensure timely follow-ups.

Transitions of Care Measure

Coordinating care for members following a hospital or ED discharges is critical for health plans in order to avoid unnecessary readmissions and ensure proper care delivery. However, transitions from acute care settings are often subject to poor care collaboration. To overcome these challenges, the Transitions of Care Measure will rate health plans on the percentage of Medicare beneficiaries 18 years and older where following discharge from an inpatient facility, the following criteria were satisfied:

  • Notification of Member Admission:
    Health plans will need to provide documentation in members’ medical records of a receipt of notification (via phone, email, fax, EMR, or ADT notification), the day of or day following members’ admissions.
  • Receipt of Discharge Information:
    Documentation must be made in members’ medical records with a receipt of discharge information on the day of, or following the member’s discharge. Documentation must include information on the member’s treating provider, procedures and/or treatment(s) provided, diagnosis at discharge, current medication list, testing results, and treatment instructions for ongoing care providers.
  • Patient Engagement:
    Organizations must show proof of engagement provided to members in the 30 days following their discharge. Member engagement includes office, at- home, telehealth, or telephonic visits.
  • Medication Reconciliation:
    Medication reconciliation must occur and be documented on the day of discharge through 30 days post-discharge (31-day window) by a prescribing practitioner, clinical pharmacist, or registered nurse.

Follow-up After Emergency Department Visit for Patients with Multiple Chronic Conditions Measure

With high-risk patients and those faced with multiple chronic conditions often being at risk for readmission, health plans need to ensure timely and proper follow-ups post-discharge from the ED or hospital. To further support these efforts, health plans will now be measured on the percentage of ED visits for members 18 years and older who have multiple high-risk, chronic conditions, where the members had a follow-up service within 7 days of their ED visit.

  • Member eligibility criteria:
    Eligible members must have two or more of the following conditions: COPD and asthma, Alzheimer’s disease and related disorders, chronic kidney disease, depression, heart failure, acute myocardial infarction, atrial fibrillation, and stroke and transient ischemic attack.
  • Follow-up services criteria:
    Follow-up services can include outpatient visits and encounters, telehealth and telephonic visits, transitional or complex care management services, case management visits, and behavioral health visits.

How to Prepare for These Changes

With these new measures, health plans should consider their existing performance measures with similar requirements, especially those that require timely follow-ups and close coordination of care. Organizations should determine real-time care coordination solutions that will enable adherence to the timeliness requirements with these two measures, and allow them to monitor member discharges to ensure coordinated follow-ups.

Additionally, organizations should look for solutions that enable close collaboration with community providers and, at the same time, improve quality performance for the Star Rating program and beyond. Additional HEDIS measures that can directly benefit from real-time member admission, discharge, and transfer data to trigger workflows and drive interventions and timely care include: 

  • Plan All-Cause Readmissions (also included as a Star Ratings measure)
  • Acute Hospital Utilization
  • ED Utilization
  • Hospitalization for Potentially Preventable Complications
  • Follow-Up After Hospitalization for Mental Illness
  • Follow-Up After ED Visit for Mental Illness
  • Follow-Up after ED Visit for Alcohol and Other Drug Abuse or Dependence
  • Prenatal and Postpartum Care

For more information on how to prepare and succeed with the newly-released measures, contact us at [email protected], or complete our contact form.