Improving Your Star Ratings with CMS Access APIs Part 2: Putting Data to Work

CMS has put a data first policy in place over the years. Many of the data requirements have targeted quality measurement. This year, CMS is going full bore on leveraging application programming interfaces (APIs), with the CMS-0057 final rule doubling down on payer-to-patient APIs and adding in payer-to-provider, payer-to-payer, and prior authorization APIs. Each of these API is required to use the FHIR data format and modern RESTful programming techniques.  

There is a hidden power in this FHIR API requirement. The natural tendency is to think about what can be done with data SHARING. Potentially as powerful is what payers can do with their data INTERNALLY. Capitated payers have fundamental needs to be able to both document and IMPROVE their performance. FHIR data and modern data stores are the natural (and arguably best) way to combine the clinical and financial (aka claims) data needed to make the case for more favorable payments.  

One place where data really comes in handy (an understatement) is in calculating CMS Star Ratings for Medicare Advantage (MA) plans. 

In Part 1 of this blog series, we provided an overview of the opportunity. In Part 2, we cover concrete examples of how payers can put data to work to impact patient outcomes and patient experience, leading to better Star Ratings.

Let’s unpack the Star Ratings opportunity

There are about 40 measures that impact a given plan’s Star Rating. The work begins by digging into each measure and imagining the actions your organization can take to positively improve performance for that measure. Then you’ll need to come up with an action plan. 

Start by asking:

• What are the incentives that each measure can be affected by?
• Where does the data come from? What are the various sources?
• Who is generating the data?
• Does performance improve based on the behavior of the patient, the behavior of the provider, or both? 

Likely what you’ll discover as you go through this process is that many of these measures can be improved simply through smarter communications. That’s smarter communication with both members and providers. 

Now, let’s look closely at specific patient-facing and provider-facing actions you can take to improve Star Ratings.

Patient-facing actions to improve Star Ratings

There are a number of patient-facing actions you can take to improve measures performance and therefore Star Ratings. These include:

• Medication adherence: Take two intermediate outcomes measures: blood pressure control and medication adherence. Probably the single biggest thing that can improve quality of life is blood pressure control. Well over half of adults in Medicare Advantage plans have blood pressure control issues. We have great, stunningly inexpensive blood pressure medicines available and a number of Stars performance measurements are based on giving the medication, getting the patient to take the medication, and targeting the right medications for a specific population. Ask yourself, how do I find the population of patients that could benefit from blood pressure control, how do I get them in front of a provider to prescribe the right medication, and what actions can I take to increase the likelihood of these patients taking the prescribed medication.

• Care coordination: Care coordination has historically been a very complicated issue because it’s primarily been a call center-mediated activity. Now, as many seniors have access to smart phones, you can think of care coordination more broadly. Ask yourself how you can improve care coordination by leveraging the smart phone these seniors carry around 24/7. 

• Prior authorization: Today, prior authorization is highly manual and non-standardized, resulting in challenges for providers, patients, and payers alike. Prior authorization can lead to negative clinical outcomes and the manual transactions are costly. With the new CMS-0057 regulations, Prior Authorization is under a microscope – at both the Congressional and agency levels.
  
  Starting in 2025, health plans impacted by CMS-0057 will need to report on prior authorizations. Automation of Prior Authorization processes can significantly increase efficiency, decrease cost, and improve patient experience and clinical outcomes. If you’re not already, you should start by evaluating your existing prior authorization vendors to better understand where data lives today, what elements of the API can be covered by these vendors, and where gaps exist. 

• App usage: The number of apps used by patients, providers, and payers are growing. Payers should think deeply about what apps they are using – and what they could be using – to improve patient-facing communications.

Provider-facing actions to improve Star Ratings

On the provider-side of the equation, to get the data you need to improve underlying performance so you get better scores, there’s lots that can be done:  

• Rosters of patients: You need to get smart on rosters of patients. If you have a data management platform that enables you to combine clinical and claims data – which is the heart of modern computing – you’ll be able to segment rosters of patients, better understand the decisions and treatments that move the needle on their health, ensure that better course of treatment, and move the needle on outcomes.

• Plan design: When it comes to plan design, you should start with your big in-network contracts. You should have a strategy in place for getting counterparty data. If you haven’t made a joint clinical and claims data agreement, you need to get the wheels in motion on this.

• Network performance measures: Network performance measures already make up a good portion of the measures algorithm. In fact, they already have a lot of network access requirements. That said, in the near future, network performance measures are going to be audited far more than they have been because CMS knows there are areas being gamed here. Therefore, you’re going to want to be ahead of that. 

What’s the opportunity for Medicare Advantage Plans

The opportunity to improve your Star Ratings is real. With access to clinical and claims data, you can improve the underlying performance of each measure that makes up your Star Ratings. But it’s about more than just getting the data, you’ll also need to take action on it. You should be thinking hard about each measure and what can be done to move the needle on that particular measurement. We hope some of the information shared above inspires you to think strategically and creatively about the actions you can take now to impact next year’s Ratings. 

Stay tuned for future blogs in this series where we dig into improving outcomes for an individual patient and the technology you need to pull this all together. You can also watch our webinar “Improving Your Star Rating with CMS Access APIs” for more insights and recommended actions and read Part 1 of this blog series if you missed it.