Enhancing Star Ratings Through a Healthcare Navigation Approach

Every year, quality improvement teams face the challenge of evaluating the care quality delivered to their members. The Star Ratings system, initiated by the Center for Medicare and Medicaid Services (CMS) in 2008, serves as the benchmark for this assessment. The five-star system encompasses over 30 quality measures derived from three categories: Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and Health Outcome Survey (HOS).

The Star Ratings system is complex and demands substantial member data, further complicated by annual updates of calculations and scoring.

Given the intricate nature of the Star Ratings program, there is no one-size-fits-all solution to manage every aspect. However, employers can implement a strategic approach, ensuring that members receive appropriate care while simultaneously reducing the burden on quality improvement teams and improving overall Star Ratings performance.

Healthcare navigation: A three-step strategy

Health plans can use healthcare navigation to capture member data within a member’s own workflow, aligning with the member’s health journey – meeting them where they are. This approach not only results in a non-intrusive and effective data collection process that decreases the burden on quality improvement teams but also builds member trust and compliance, with the added benefit of reducing member attrition and increasing engagement.

Welcoming a new member

Creating a positive onboarding experience for new members is a critical first step. Healthcare navigation can provide clear and accessible information, setting the stage for a member’s journey with their health plan. Health plans can also leverage healthcare navigation to gather health information about the member, understand their care needs and identify potential gaps.

Year-round healthcare navigation

Understanding and actively participating in a member’s health journey is key to positively influencing measures in the five ratings domains:

• Staying Healthy: Screenings, Tests, Vaccines
• Managing Chronic (Long-Term) Conditions
• Member Experience
• Member Complaints and Changes in Plan Performance
• Health Plan Customer Service

A proactive approach involves personalized care coordination, ensuring that members receive timely screenings and tests, effectively manage chronic conditions, and have a positive overall experience with their health plan.

For this process to succeed, it’s key to establish ongoing engagement and support, which healthcare navigation provides in multiple areas:

• Early interventions to avoid care delays
• Benefits and scheduling support
• Care guidance throughout the year
• Access to health maintenance resources
• Management of prior authorizations

Technology plans a key role in making healthcare navigation accessible and effective; however, human-to-human interaction leads to increased engagement, especially in the senior population.

Targeted gap closure

Identifying and addressing care gaps is crucial for health plans aiming to improve Star Ratings. The ideal means is to have a foundation of engagement and trust with members and providers built through time with a healthcare navigation solution. If the member is familiar with their care coordinator, they will naturally engage with their care, and in turn increase compliance and care gap closure.

“Members often have benefits that they don’t know about. That usually saves the member either money or lots of time.” - Athena, Quantum Health Care Coordinator