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2023 CMS Star Ratings: How better member targeting and intervention planning impacted plan performance

Inovalon customer performance versus the market for 2023 CMS Star Ratings

The Centers for Medicare & Medicaid Services (CMS) on October 6 released the 2023 Star Ratings for Medicare Advantage (MA) and Prescription Drug Plans (PDPs). Overall, plan performance for 2023 Star Ratings declined an average of .25 stars from 2022 ratings – on par with plan performance in 2020, prior to the COVID-19 pandemic. This is an outcome not many were surprised by as pandemic-era flexibilities to support health plans during the height of the COVID-19 public health emergency (PHE) were rolled back.

For 2023 Star Ratings – while lower measure performance was seen largely across the board – Inovalon’s quality measurement and reporting customers were a bright spot, outperforming the national average in key measure categories. Overall, Inovalon partners with more than 60% of MA plans rated at 5 stars and 62% of MA plans rated at or below 3.5 stars for 2023 ratings. Analysis of health plans with ratings below the 4 star threshold reveals that those utilizing Inovalon’s Converged Quality cloud solution, realized an average rating increase of more than 10% across the Hybrid and Non-Clinical measure categories – marking a significant achievement in their performance.

Lower performing customers saw average increases across measure categories from 2022 by leveraging Inovalon’s data-driven intervention analytics, planning, and execution capabilities. Timely insights into measure performance throughout the year, analytically-driven intervention planning and prioritization, and patient-specific intervention outreach helped these plans address quality measure gaps during the 2021 measurement year – contributing to their above average performance improvement for 2023 Star Ratings.

Impact of methodology and cut point changes on CMS 2023 Star Rating performance

Issued annually each fall, MA Star Ratings were created to provide healthcare beneficiaries with information to help them choose quality health plans. CMS utilizes a range of data sources to assign Star Ratings – including data from health plans, patient surveys like CAHPS[1] and HOS[2], CMS Administrative data, and data from CMS contractors.

Across contract types, the 2023 Star Ratings included a maximum of nine domains, comprised of a maximum of 40 measures:

    • MA-only contracts were measured on five domains with a maximum of 28 measures
    • PDP contracts were measured on four domains with a maximum of 12 measures
    • Medicare Advantage Prescription Drug (MA-PD) contracts were measured on all nine domains with a maximum of 40 measures, 38 of which are unique measures

Methodology changes

Each year, MA plans must adapt to changes in CMS Star Ratings methodology – and the 2023 Star Ratings were no different. Perhaps the biggest update impacting health plan performance for 2023 Star Ratings was the elimination of the Better Of provision applied in 2022.

For 2022 Star Ratings, measure-level adjustments were permitted under the PHE that allowed health plans to use 2021 measure-level Star Ratings if their 2022 measure-level ratings were lower. Per CMS, for the 2023 Star Ratings the only PHE-related adjustments are measure-level adjustments for three Healthcare Effectiveness Data and Information Set (HEDIS®) measures from the 2021 Health Outcomes Survey (HOS):

    • Monitoring Physical Activity
    • Reducing the Risk of Falling
    • Improving Bladder Control

In addition to this significant update, other key changes in CMS Star Ratings methodology from 2022 included:

    • The weighting of patient experience and access measures increased from two to four
    • Controlling Blood Pressure (CBP) was added as a new measure with a weight of one for the first year
    • The Part D Statin Use in Persons with Diabetes (SUPD) measure weighting decreased from three to one
    • The Rheumatoid Arthritis Management (ART) measure was retired

The weighting increase for patient experience and access measures reflects the higher emphasis CMS is putting on these areas and is a likely contributor to the lower performance seen in the 2023 ratings. Patient experience measures, in particular, can be challenging for health plans to move the needle on as they are based on patient-reported outcomes through surveys like CAHPS.

Measure-level cut points

Another factor that had an impact on MA plan performance for 2023 Star Ratings is related to measure-level cut points. A comparison of 2022 versus 2023 cut points demonstrates that the majority of cut points moved down from 2022 – an area of exception being Medication Adherence measures, which saw an increase in measure-level cut points almost across the board.

The trend of downward cut point movement indicates that overall plan performance was lower between the 2020 and 2021 measurement years. Given early 2020 marked the start of the global COVID-19 pandemic, this was in many ways to be expected. Conversely, the increase seen in Medication Adherence measure-level cut points means MA plans that maintained performance from 2022 likely rated lower on these measures in 2023.

Additionally, CMS this year introduced cut point guardrails for measures used in Star Ratings for three (3) years, except CAHPS and improvement measures. These guardrails limit cut point movement – up or down – to no more than five percent. For 2023 and going forward, plans can expect to see more limited cut point movement for established measures, even if plan performance warrants a more significant shift.

Looking ahead to 2024 CMS Star Ratings

It’s never too early to begin preparing for next year’s Star Ratings. For 2024, MA plans should keep in mind the following changes:

    • New measures: Three (3) new measures will be added to 2024 Star Ratings. These measures are not new to HEDIS, only to Star Ratings:
Measure Name Type Calculation
Transitions of Care (TRC) Clinical Hybrid Average of the 4 TRC Total measures (TRC-Medication Reconciliation Post Discharge Total, TRC- Notification of Inpatient Admission Total, TRC-Patient Engagement After Inpatient Admission Total, TRC-Receipt of Discharge Information Total)
Follow-up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC) Clinical Admin FMC-Total
Plan All-Cause Readmissions (PCR) Clinical Admin Weighted average methodology (to calculate the 18+ buckets laid out in the CMS specifications)
    • Removed measures: The Medication Reconciliation Post-Discharge (MRP) measure is not applicable for 2024 Star Ratings. This measure has been now merged as part of the TRC measure
    • Measure weights: The Controlling High Blood Pressure (CBP) measure weight will increase from one (1) to three (3) for 2024 Star Ratings, which means CBP rates will contribute more towards overall Part-C and Overall Star Ratings
    • Sub-measures: The Comprehensive Diabetes Care (CDC) sub-measures will become standalone measures for the HEDIS measurement year 2022 catalog:
      • Hemoglobin A1c Control for Patients with Diabetes (HBD)
      • Blood Pressure Control for Patients with Diabetes (BPD)
      • Eye Exam for Patients with Diabetes (EED)
    • Tukey method: CMS will implement the Tukey method for 2024 Star Ratings, which will remove extreme outliers from measure scores prior to determination of the CMS cut points. This change will likely make it more difficult for MA plans to earn (or keep) their Star Ratings; however, minimal impact to the Four and Five Star cut points is expected.

For lower performing MA plans, those with access to comprehensive data sources and predictive forecasting will be best equipped to adapt amid upcoming changes to CMS cut point determination methodology via the Tukey method.

Achieve your quality improvement goals with Inovalon

Inovalon enables more than 100 health plans annually with our Converged Quality cloud solution, which processes nearly 190 million lives for quality reporting purposes, including more than 80% of all HEDIS covered lives.

If you are looking for experience you can trust, contact us to schedule a demo and learn how Inovalon can help you achieve quality excellence.

[1] Consumer Assessment of Healthcare Providers and Systems
[2] Health Outcomes Survey
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Inovalon and design® and Inovalon® are trademarks of Inovalon, Inc.

By Courtney Breece, Associate Vice President, Payer Product

Courtney’s passion lies in healthcare quality. She held multiple leadership roles at NCQA before joining Inovalon in 2012, where she leads the company’s integrated approach to payer analytics for both quality measurement and risk adjustment.