News & Insights


Webinar Recap: The Outlook for Government Sponsored Health Programs under the Trump Administration & How to Save Your Star Rating

On March 21st, close to 100 attendees from a myriad of health plans across the country came together for a webinar presentation facilitated by Novitex, and delivered by John Gorman, Founder and Executive Chairman of the Gorman Health Group – a leading consulting firm specializing in government health programs, including Medicare, Medicaid and Health Insurance Exchange opportunities. The presentation focused on actionable steps health plans can take to preserve and even raise their Star Ratings – a crucial metric that is used to rank health plans comparatively (you can access a full recording of the webinar here).

The idea of health plan Star Ratings is a simple one. The Centers for Medicaid Services (CMS) assigns a value to each health plan, with one star representing a poor plan, and five stars representing an excellent one. The metrics that determine these Star Ratings run across five general categories – customer service, customer complaints, effective improvement of physical or mental health, effective chronic condition management, and overall member satisfaction.

Because of the massive implications these ratings hold for plans, combined with the uncertainty they now face from a regulatory standpoint, this was a timely presentation. Gorman covered substantial ground within the hour-long webinar, so we have broken it all down into five main takeaways.

1) Star Ratings Drive Enrollment – and Provide Other Financial Benefits

While it is well-known that Star Ratings impact the health plan market, the extent to which it is true is often acknowledged to a lesser degree. Because not only do high ratings create more interest in a plan, but there are also direct financial benefits, as Medicare pays bonuses to plans that earn four or five Star Ratings. Until 2015, Medicare also paid additional incentives to three Star plans, but that policy has been eliminated. Incentives are substantial as well, up to $500 per member according to some estimates. The image below, taken from Mr. Gorman’s presentation, shows some of the positive, or negative effects that are symptomatic of high or low Star Ratings.


2) Star Ratings Metrics May Change

While there is a consensus that Star Ratings carry substantial importance for health plans, what is becoming increasingly less clear is what metrics will determine these Ratings for health plans in the future. Tom Price, the new Secretary of Health and Human Services under the Trump administration may have very different preferences in terms of what metrics are considered important for determining Star Ratings than his predecessor did, as Gorman laid out below: 


3) The Member Experience Makes Up Half of a Plan’s Star Rating

Member experience and complaints are weighed heavily by the CMS when they determine annual Star Ratings for health plans, accounting for nearly half of the metrics they consider in determining these rankings. For health plans, this means that internal investments and staffing need to reflect this emphasis. Granular metrics like time to answer or return phone calls, or even how long patients wait at a provider’s office, are measured – so health plans need to have a similarly intensive focus on providing a top-quality customer experience. While the plan itself cannot control all variables (patient wait times, for example), there are other factors they have complete control over.


4) Actionable Steps to ‘Save the Star’

Having established the importance of customer experience to CMS Star Ratings, Gorman delved into some steps health plans can take to preserve and/or raise their Star Ratings. Communications, in large part, helps create the member experience. Therefore, high performing plans often do an above-average job of helping members understand and use their benefits. They simplify written communications, by making each piece more meaningful, instead of sending a voluminous stream of communications that only include sparse, or difficult to understand information. And ultimately, high performing plans understand that one of the most important communications they share with constituents in terms of creating a positive or negative customer experience, is the provider directory.


5) Why Consistent, High-Quality Communications can Equal Higher Star Ratings                                     

We know that member experience weighs heavily on the CMS scales as they assign yearly Star Ratings. We also know that communications help drive this experience substantially. Which means, if Provider Directory information is incorrect, and a member receives a surprise charge, drives to an incorrect address, or is otherwise negatively affected – those missteps may be reflected in a lower rating when 2018 Stars are assigned this October. Consequently, driving consistent, high-quality, and up-to-date communications should be a high priority for all health plan managers and executives.


Despite all this, an in-presentation survey (shown above) revealed the majority of health plans are still handling provider directory responsibilities in-house. While regular maintenance of health plan web sites and portals can help maintain the data accuracy of digital directories, keeping printed versions updated is trickier. CMS mandates that physical directories must be updated at a rate of once per month – a task which is manageable with proper print production strategies in place, but a mandate that can be challenging for health plans managing an in-house, or ad-hoc print strategy.

But Gorman did note that there were providers, such as Novitex, who can handle these document production and distribution responsibilities in an end-to-end fashion. And that partnering with such an external vendor represents a viable strategy to keep these printed documents accurate and up-to-date, which can help keep complaints down, and Star Ratings up.

One final takeaway from the presentation was that health plans are facing a period of unprecedented uncertainty in their industry. But while the challenges they face, in terms of creating the conditions necessary to provide a consistently positive experience for their members, and in turn, earn a high CMS Star rating are incredibly challenging – plans do not need to face them alone. 

Learn more about Novitex's solution, Healthcare Connect, which can help you streamline your provider directory updates and avoid CMS fines and sanctions.

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