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Webinar Summary: How to Improve your CMS 5-Star Quality Rating

Those of us who work in Healthcare are very versed in the ways of changing government regulation, undefined or under defined requirements to meet these regulations and timelines that are either tough to meet or totally unrealistic. The multiple components of the Accountable Care Act, signed into law in 2010 meet all the undefined, changing timelines and then some.

The goals of the Affordable Care Act (ACA) are pretty straightforward; to provide Americans with better health security by putting into place comprehensive health insurance reforms that will:

  • Expand coverage
  • Hold insurance companies accountable
  • Lower health care costs
  • Guarantee more choice
  • Enhance the quality of care provided

In order to comply with the ACA, providers have been tasked with reducing reimbursements by 14% nationwide beginning in 2017. CMS is taking a balanced scorecard approach to tracking performance by reviewing process-based clinical and quality performance metrics as well as the customer service indicators reported by plan members. The calculation of results will define the provider’s CMS Quality 5-Star Rating.

Ratings of 1-5 stars are awarded to Medicare health and prescription drug plans based on overall performance. Customers and potential customers can then have access to compare plans based on quality, performance and patient satisfaction measures defined to, in turn, improve patient clinical outcomes, lower cost and enhance the overall patient experience.

On the business end, Health plans and physicians are just being asked to identify and improve gaps in care directly connected to Medicare Services reimbursements and patient outcomes.

Sounds pretty simple right? So what’s the big deal?


The big deal is it is not as simple as it sounds. There are multiple parties engaged on each goal above, there is still debate on how it should be done, and it has only been 5 years and healthcare providers are still not ready for the change. Additionally, failure to act can be detrimental, causing providers to risk losing plan membership and revenue.

After the initial access snafu in 2013 related to the registration process, it appears that has made most of the necessary changes to expand coverage to the uninsured and provide more choice in coverage. However, how do we hold insurance companies accountable to lower healthcare costs and enhance the quality of care provided?

The balanced scorecard approach is a good one but the devil is in the details. How do you take aggregated results that were used to calculate your 5-Star Ratings for 2015 and make them actionable NOW? Start now and get ahead of next years results! You may not be able to change your 2015 rating but you can absolutely affect your rating next year by implementing near real-time tracking and monitoring of activity in the key performing areas:

  • Staying healthy:
    Screenings, tests and vaccines (such as annual PCP visits, and colorectal cancer screening).
  • Managing chronic conditions:
    Diabetes, COPD, CHF, etc.
  • Plan responsiveness, care and quality:
    Getting needed care as well as getting appointments and care quickly.
  • Member complaints, problems getting services and choosing to leave the plan:
    Such as complaints about the health plan, etc.
  • Customer service:
    Such as timely appeal decisions, etc.

Maybe you already have Population Health initiatives to control management of chronic conditions but how are you tracking member leakage? Your customer service scores are high but HEDIS data says you are lagging in flu vaccines and BMI screenings. The key is to get the right team around you who has done this before to wade through the noise and simplify to process.


Business Intelligence tools are great for helping you build scorecards and dashboards for tracking chronic condition management and screening compliance. I have personally been involved in reporting projects that successfully helped providers increase the quality of care provided to their patients by double digits in six months, simply by bringing visibility to the issue.

Think about bringing a customer experience management (CEM) vendor to the table to help you quickly identify what members are saying about you, helping you create a plan of attack to reduce member complaints and increase plan responsiveness.

Now is the time to plan your attack on those 2016 5-Star Quality Ratings. Starting now can mean a huge difference in your bottom line since improving your rating by a single rank yields an estimated $40-$60 per member, per month! Based on 100,000 plan members, that translates to the potential to recoup an additional $5 million dollars in reimbursements every month!

To learn more about how to simplify the process and improve your rating, please reach out to us. We will be happy to help!

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