Introduction
Managing the 42 measures that make up CMS’ Medicare Advantage (MA) Stars scoring system is a complex and data intensive endeavor. One of the ways that Lilac breaks this unwieldy challenge down is by grouping measures into categories that share a similar set of data inputs and activity types required to drive performance.
We’re kicking off a series of articles that explain how we group measures at Lilac, which is reflected in our Stars Management Platform, and then lay out best practices to drive high performance in each group.
This article covers the measure group: Clinical Measures.
Clinical Measures Defined
Simply put, what Lilac categorizes as Clinical Measures are the measures that are part of the MA Stars program and calculated using NCQA HEDIS measurements. This group of measures includes those that pertain to preventive and routine health screenings, chronic disease management, and comprehensive care for older adults. These measures are interconnected through their emphasis on proactive and consistent member care to prevent severe health complications and improve overall quality of life.
Included Measures
C01: Breast Cancer Screening
C02: Colorectal Cancer Screening
C06: Care for Older Adults – Medication Review
C07: Care for Older Adults – Pain Assessment (will be temporarily removed in SY 2027)
C08: Osteoporosis Management in Women who had a Fracture
C09: Diabetes Care – Eye Exam
C10: Diabetes Care – Blood Sugar Controlled
C11: Controlling Blood Pressure
New: Kidney Health Evaluation for Patients with Diabetes (SY 2026)
Returning: Care for Older Adults – Functional Status Assessment (SY 2027)
Common Challenges in Achieving High Scores
Delivering high performance across Clinical Measures is complex due to the multifaceted nature of maintaining health in elderly and diverse populations. Some of the most common challenges plans need to be prepared to overcome include:
- Patient Engagement & Adherence
Low Patient Engagement: Many members may not be fully aware of the importance of preventive screenings or routine assessments. Member outreach and education is essential but the most important members to reach are often the most challenging to influence.Adherence to Treatment Plans: Ensuring adherence is especially challenging in chronic disease management (e.g., blood sugar control, controlling blood pressure) where lifestyle changes, consistent medication, and regular monitoring are essential. - Social Determinants of Health (SDOH)
Access to Care: Socioeconomic factors such as transportation, income, and education level can create barriers to accessing necessary screenings or follow-up care.Health Literacy: Patients with limited health literacy may struggle to understand the importance of certain screenings or how to manage chronic conditions, leading to lower adherence and missed opportunities for preventive care. Targeted strategies focusing on a plan’s most at-risk members is essential. - Data Collection & Integration
Fragmented Health Data: Data is often siloed across systems, tools and providers, making it difficult to create a complete picture of patient health. This hinders effective coordination and prevents timely interventions.Timely & Accurate Reporting: Stars measures require accurate and up-to-date reporting, but delays in claims data, medical record reviews, and lab results can impact performance assessments. - Provider Engagement & Alignment
Coordination Across Providers: Many of these measures require coordinated care across primary care physicians, specialists, and pharmacists. Misalignment or communication gaps between providers can lead to incomplete or delayed care, especially with high risk populations.Inconsistent Documentation: For Clinical Measure in particular accurate documentation is critical. If a plan is not proactively stating on top of all necessary records like functional status, pain assessments, or medication reviews, it can lead to gaps in reporting. - Resource Constraints
Staff Empowerment: Achieving high Stars performance requires substantial patient outreach and follow-ups, which are labor-intensive. Optimizing staff productivity with clean, timely data can drive score performance while reducing labor costs.Technology Infrastructure Limitations: Not all plans have access to advanced technology tools for efficient patient tracking, analytics, or the latest modes of care. This can limit the ability to identify and engage high-risk patients effectively or to streamline data reporting and compliance processes. - Member Behavioral & Lifestyle Factors
Lifestyle Changes for Chronic Management: For chronic disease measures, controlling blood pressure or blood sugar often requires patients to make sustained lifestyle changes, which can be difficult to influence and sustain.Complex Comorbidities: Patients with multiple chronic conditions may need highly individualized care plans that are challenging to manage within standardized Stars requirements. - Regulatory & Compliance Challenges
Evolving Requirements: Medicare Advantage Stars measures change from year to year, requiring plans to quickly adapt to new performance metrics or documentation standards.Compliance with Documentation Standards: High performance requires accurate, compliant documentation, which can be challenging if workflows are not optimized for Stars reporting.
Management and Gap Closure Best Practices
Performing well on Stars Clinical Measures requires an MA plan to take a holistic and integrated approach. Below are a set of best practices that enable a plan to systematically drive member health quality, improve member satisfaction, and maximize their Stars ratings. The
- Patient Engagement and Education
Tailored Education Programs: Develop patient education programs that explain the importance of initiatives tied to each measure, particularly preventive screenings and chronic disease management. This should include clear, understandable information about why measures like diabetes care and cancer screenings are essential for long-term health.Incentive Programs: Implement incentive programs for completing preventive screenings, annual check-ups, and routine assessments. These can include rewards, gift cards, or premium discounts for members who meet certain health goals.Diversified Outreach Channels: Use multiple channels for outreach, including text messages, phone calls, emails,community based events and patient portals, to remind members of upcoming screenings, appointments, and medication refills.Accessibility of Health Literacy Support: Ensure materials are accessible to all health literacy levels and provide multilingual support as needed to reach all populations covered by a plan. - Data Management and Analytics
Analytics for Risk Stratification: Use predictive analytics to identify high-risk patients who would benefit most from proactive interventions. For example, analytics can highlight patients with a history of diabetes who are overdue for an eye exam or kidney evaluation.Data Integration: Integrate claims data with encounter note and supplemental benefit utilization to create a comprehensive view of every patient to understand their needs and propensity to act. This helps with identifying gaps in care, whether patients are up-to-date with their screenings/ assessments and which outreach strategies are most likely to be effective.Always On Dashboards: Eliminate data lags by creating frequently refreshed dashboards to monitor performance on each Clinical Measure and identify areas needing urgent attention. This can also help ensure data accuracy and timely reporting.
Data Sharing Across Providers: Enable seamless data sharing among primary care physicians, specialists, and care coordinators to improve continuity of care, prevent redundant tests, and ensure highest risk populations get special attention.
- Care Coordination and Case Management
Dedicated Care Coordinators: Assign dedicated care coordinators to high-risk patients or those with chronic conditions. Care coordinators can manage patient appointments, follow up on screenings, and provide reminders for preventive services.
Multidisciplinary Care Teams: Develop multidisciplinary care teams that include primary care providers, specialists, nurses, pharmacists, and social workers to manage patients’ comprehensive needs, especially for older adults.Chronic Disease Management Programs: Create structured chronic disease management programs that emphasize routine monitoring, medication adherence, and lifestyle modifications. These programs should address diabetes, blood pressure control, and kidney health for patients with chronic conditions.Telehealth and Home Care Services: Offer telehealth and home care options for follow-ups and routine assessments to make it easier for patients, particularly those who are resistant to visiting medical facilities, to access care. - Provider Engagement and Education
Ongoing Provider Training: Provide regular training for healthcare providers on Stars measures, including best practices for meeting these requirements and accurately documenting care. For example, providers should be trained on the specific documentation required across Clinical, Complex Clinical and Medication Adherence Measures.
Aligned Incentives for Providers: Implement performance-based incentives to reward providers who meet or exceed targets for Stars measures. This can motivate providers to prioritize preventive care, screenings, and chronic disease management.
Decision Support Tools: Equip providers with decision support tools and reports that easily integrate into an EHR to prompt screenings, tests, and assessments based on patient history and clinical guidelines.
Collaborative Goal Setting: Engage providers in setting shared goals for Stars measures performance, encouraging a team-based approach to improving patient outcomes and compliance with care protocols.
- Addressing Social Determinants of Health (SDOH)Transportation Assistance: Offer transportation assistance programs to help patients access healthcare services, particularly for screenings and routine check-ups.Community-Based Resources: Partner with community organizations to address food insecurity, housing instability, and other social determinants of health that can impact patients’ ability to adhere to care plans.
Culturally Competent Care: Provide culturally competent care training for staff and providers to ensure that patients from diverse backgrounds feel comfortable accessing preventive and chronic disease care.
- Quality Improvement and Continuous MonitoringRegular Performance Reviews: Conduct monthly performance reviews for each Stars measure to track progress, identify gaps, and implement targeted interventions where needed. Every quarter run a more robust Stars strategy review to ensure focus and resources are being allocated optimally.Patient Feedback Mechanisms: Implement member feedback mechanisms to gather insights on patient experience and identify areas where care delivery can be improved to better meet patients’ needs.Continuous Quality Improvement (CQI) Processes: Integrate CQI processes into daily operations to make iterative improvements based on data, patient feedback, and changes in a plan’s Stars requirements.
- Leveraging Technology and AutomationAutomated Patient Reminders: Use automated systems to send reminders for screenings, medication refills, and annual wellness visits. Automation reduces the manual workload on staff and helps ensure consistent outreach.AI-Powered Predictive Tools: Employ AI-powered tools to predict which patients are most and least likely to take certain actions to develop proactive plans involving providers and community based organizations to optimize chances for gap closure.Telemonitoring for Chronic Conditions: For high-risk patients, telemonitoring devices (e.g., for blood glucose or blood pressure) can provide real-time data to care managers and help prevent acute episodes by allowing early intervention.
——————————————-
If you want to explore how we can help your plan, reach out to us via the form in this link to start the conversation.
