利用卓越运营：通过有效适应提高医疗保险星级

11,2,3.. This paper explores potential operational implications and February 2024 Leveraging operational excellence:Enhancing Medicare Star Ratings through effective adaptation2Background: Evolution of Medicare Advantage Star Rating systemThe release of the 2024 Star Ratings revealed unexpected lower ratings for many health plans due to the removal by the Centers forMedicare and Medicaid Services (CMS) of Tukey outliers in measure cut points, indicating the start of significant changes to theMedicare Advantage (MA) Star Rating system. CMS indicates that these changes are intended to reward quality, enhance stability, andfoster health equity, but they are expected to lead to funding reductions in the MA program.The following are new and upcoming methodology changes coming to the MA Star Rating system.Tukey outlier removal:CMS began excluding Tukey outliers from all cut point calculations in the 2024 Star Ratings (2025payment year) for all non-Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures, in an attempt tostabilize annual cut point shifts caused by low-performing contracts. Despite regulations suggesting a gradual implementation with5% guardrails, the change had an immediate and comprehensive effect, as CMS recalculated the 2023 cut points without includingTukey outliers. CMS projected it would save $935 million in 2025, increasing to $1.5 billion by 2030.4Contracts with Star ratingsbetween 3.5 and 4.0 Stars are expected to absorb the CMS savings through revenue reductions related to star ratings.HEI rewards system:Starting in 2027, the Medicare Advantage Star Ratings will adopt a new HEI rewards system, prioritizingsocial risk factor (SRF) populations. This system will benefit contracts providing high-quality healthcare to low-income, dual-eligible,and disabled populations. CMS simulations indicate that this change could save the government $670 million by 2028.5primarilyby reducing rebates for 4.5-Star contracts.Measure and weight changes:Beginning with the 2026 Star Ratings (2027 payment year), CMS will reduce the weight of patientexperience, complaints, and access measures from four to two, increasing the importance of claim-based measures from 30% inplan year (PYr) 2024 to 53% in PYr 2027.6This shift includes removing measures, adding measures, and modifying specificationsfor existing measures. CMS estimates this change will lower program expenses for the government by $330 million in 2027,reaching $580 million by 2033.7Hold harmless and other unfinalized rules:Medicare Star Ratings are calculated both with and without improvement measures;for contracts already over 4.0 Stars, CMS uses the higher score to reflect the challenge of continuous improvement at higherperformance levels. CMS proposed raising the threshold from 4.0 to 5.0 Stars for the 2026 Star Ratings, potentially saving thegovernment $2.1 billion in 20278with cost savings coming from reduced revenues for existing 4.0- and 4.5-Star contracts. Whilenot finalized in the 2024 Final Rule, CMS intends to implement this change in the future.4See Tukey Outlier CMS Cost Savings, Table 12, in the 2021 Final Rule, available athttps://www.federalregister.gov/documents/2020/06/02/2020-11342/medicare-program-contract-year-2021-policy-and-technical-changes-to-the-medicare-advantage-program5See Table 1 in the 2024 Final Rule, available athttps://public-inspection.federalregister.gov/2023-07115.pdf.6Claim-based measures include HEDIS, HEDIS Health Outcomes Survey (HEDIS-HOS), Prescription Drug Event (PDE), PDE/Medicare Plan Finder (MPF) and Part C/D Planreporting data types. Non-claim-based measures include CAHPS, HOS, Complaint Tracking Module (CTM), Medicare Beneficiary Database Suite of Systems (MBDSS)Independent Review Entity (IRE) and Call Center data types.7CMS, 2024 Final Rule, op cit.8CMS, 2024 Final Rule, op cit. February 2024 Leveraging operational excellence:Enhancing Medicare Star Ratings through effective adaptation3February 2024Using internal models that replicate Star Rating methodologies, we conducted simulations to evaluate the effects of the aforementionedmethodology changes. These assessments were done under two scenarios: keeping the current hold harmless threshold at 4.0 Starsand increasing it to 5.0. Figure 1 displays the estimated impacts of these changes, utilizing September 2023 membership data and thelatest Star Ratings for each contract.Our projections indicate a historical decline in average Star Ratings, which could fall to as low as 3.91 by the 2027 Star Ratings (2028payment year). Such a decrease would represent the lowest national average since the conclusion of the Quality Bonus Paymentdemonstration in 2014.FIGURE 1: ESTIMATED MEMBER-WEIGHTED AVERAGE STAR RATING BY STAR RATING YEAR (SY) AND PAYMENT YEAR (PY)To demonstrate the potential effects of Star Rating changes on individual contracts, Figure 2 presents the revenue impacts on plansaccording to their Star Ratings and bid-to-benchmark rati