While Medicare Advantage (MA) plans are broadly challenged by the Star program’s clinical measures, it is fair to say that almost every plan finds the so-called “complex clinical measures” acutely difficult.
What are the measures in question?
The complex clinical measures (also called the “event-based measures”) currently in the Star program are the following:
— Medication Reconciliation Post Discharge
— Plan All-Cause Readmissions (this becomes a 3-weight as of Star Year 2025)
— Transitions of Care
— Follow-up after Emergency Department Visit Department for People with Multiple High-Risk Chronic Conditions
This is the current list but we expect that the Centers for Medicare and Medicaid Services (CMS) will continue to create more of these event-based measures in the Star program.
Why is achievement on these measures challenging?
On most clinical measures, with the right data it is fairly easy to identify members who are non-compliant. You assemble claims and various other data to ascertain when someone last received a test or what the outcome was. Then you intervene with the members and providers to move the non-compliant members to compliance.
The problem with the four complex clinical, event-based measures is you never quite know who will be in the measure universe or when. They have multiple components that need to be tracked and fulfilled. It takes an emergency department visit or inpatient visit to trigger inclusion in the measure for a given member. What’s more, data related to the event could be delayed, meaning a plan has a short timeframe or potentially no time at all to address compliance with the complex clinical measures. Indeed, the Star tasks on three of the measures must be completed within 30 days. For the Follow-up measure, the timing is just 7 days.
Best practices on the measures
There are a number of best practices MA plans can use to hone their approach on these tougher measures. The practices suggested below can reduce the number of events themselves or allow sufficient time to intervene with the member when triggering events inevitably happen.
1 — Use and maximize Admission, Discharge and Transition (ADT) electronic communications if possible. Connect directly with your providers, clearinghouses and health information exchanges. ADT investments offer the best chance of identifying these events as quickly as possible. Downstream notification of the inpatient or emergency room events quickly to relevant plan departments is critical.
2 — Strong coordination between your quality, care management, medical utilization management, and pharmacy departments is key. Each plays a critical role in success on these measures. It is critical that authorization and care management information be shared in real-time to ensure the greatest amount of time to intervene on the complex measures. As well, sharing in real-time terminations of coverage under the MA plan benefit is critical.
3 – Ensure bidirectional communication on these emergency room and inpatient events with your subcontracted entities and providers. Establish clear, efficient communication with the external parties that are closest to your members and will play a critical role in ensuring compliance.
4 — Empower your primary care physicians to be responsible and help close these measures. Educate and incentivize them. Various quality bonus approaches can be used if the providers are not under a partial or full risk arrangement.
5 — Ongoing updates to the events are key to know if you are being successful checking the boxes on each measure. Report out your performance to all critical plan departments, downstream entities, and providers. Identify and action where there are consistent breakdowns.
6 — Tracking care transitions and the right intervention plans are key for success. While much of this is real-time data, analyzing historic data is also key. That data analysis can help find providers and facilities that are not setting up the right transition plans or are not vested in quality outcomes. It also can identify those most at risk of triggering these measures.
7 — Staff your case and disease management and transition teams adequately. Adequate care management of the multiply co-morbid and those at high risk is crucial. This will pay huge dividends over time on the quality revenue and cost fronts.
8 — Establish a complex clinical measure subgroup that can create strategies to improve over time. Give responsibility to a working group whose goals are around performance in these areas.
9 — Connect these measures to your ongoing medical economics activities. Fold efforts to improve performance in complex-clinical measures into your overall medical economics management. In addition to being important Star measures, these areas have huge implications to medical costs.
The bottom line: improving these measures takes a bunch of coordination, analytical sophistication and serious thinking. Driving consistent high performance takes dedicated effort but the benefits to your bottom line and member well being are worth it. Be bold!
Lilac Software is building a revolutionary data analytics platform with a strong Stars use case. We track and trend Star performance and forecast aggregate Star scores along the way. We also use these best practice groupings noted above to provide the greatest amount of insight possible to drive improvement in Star and enrollee outcomes.
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Lilac Software offers a cloud-hosted, data aggregation and analytics solution for health plans’ most complex problems. Our Star Performance Management Platform gives unprecedented insight into all aspects of the Medicare Advantage Star program, including individual measure performance, best practice remediations for all measures, and forecasting of aggregate scores and revenue.
The platform has dedicated reporting and functionality to help plans manage complex-clinical measures. Reach out to us with the link below to learn how we can help your plan perform better in these critical areas.
