Achieve Five Star Ratings: What Health Plan Professionals Need to Know

January 5, 2016

A star rating is meant to be an 'at-a-glance' tool for prospective members to shop for health care plans. Unfortunately, a star rating doesn't tell the whole story of a health care plan and is incapable of providing all the important details.

Nonetheless, your star rating is an imperative part of your business and needs to be as high as it can be. To accomplish this, you need to understand the annual costs associated with certain medical issues, the weight they carry in CMS ratings, and which tests and procedures are best for improving.

Here are 5 effective ways to achieve five-star ratings:  

1. Osteoporosis Screenings  

Perform non-invasive ultrasounds on women with a recent fracture, ages 65 and over. Osteoporosis screenings carry a CMS weight of 1, but have been shown to improve star ratings by 3 stars.

National annual costs associated with osteoporosis and fractures have doubled since 2002, and are expected to continue. The National Center for Biotechnology Information (NCBI) reported that of the 30.2 million elderly Medicare recipients that year, 8.8 million were treated for osteoporosis and or fractures; implying a direct medical treatment cost of $10 to $17 billion per year. As of August of 2015, costs are trending at $22 billion.

NCBI also projected that "given the aging population, by 2025, annual direct costs from osteoporosis are expected to reach approximately $25.3 billion."

Move your plan up by one or more stars within a year by providing in-home bone mineral density testing to your qualified members.


2. Diabetic Retinopathy Exam (DRE)

Diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness in American adults. According to the Centers for Disease Control and Prevention (CDC), costs associated with diabetes-related blindness are $500 million annually.   

With a single CMS weight, performing Diabetic Retinopathy Exam’s on your diabetic members can potentially move your plan up by two stars in one year.

Perform DRE's with one of the following options: technician and retinal camera; nurse practitioner and retinal camera during a HRA; or an optometrist and comprehensive eye exam.


3. Post Hospital Discharge Visits

One of the key components in health care reform is identifying key risk factors that could lead to re-hospitalization. In 2014, the Agency for Healthcare Research and Quality (AHRQ) reported annual costs associated with hospital readmission were over $41 billion.  

Post hospital discharge visits are heavily weighted and carry a CMS weight of 3.

By providing medication reconciliation & counseling, follow-up for continuity of care, and ensuring patient understanding of sending physician post-hospital regimen; it is possible to reduce re-hospitalizations by 29%.


4. Blood Pressure (BP) Control

The CDC reports that there are $46 billion in annual costs in health care services, medications and missed days of work, associated with blood pressure(BP) control.  

With a CMS weight of three, blood pressure control can improve your star ratings by two stars in one year.

Offer screenings to identify, monitor and treat blood pressure to help members gain control in terms of their heart health. Taking control of blood pressure will require several visits.


5. HGBA1C Control

With diabetes being one of the most common all chronic diseases, the annual costs are staggering. Research provided by the American Diabetes Association shows that there are $153 billion in excess medical costs, and $65 billion in lost productivity associated with direct medical care for diabetes.

Provide members with Hemoglobin A1C tests to identify, monitor, and treat this devastating chronic disease.

The offered screenings can increase your rating by 1 or more stars on this high scoring measure.


The previously  mentioned offerings will play a significant role in your star improvement strategy. Render osteoporosis screenings, diabetic retinopathy exams, hospital discharge visits, blood pressure control, and HGBA1C screenings to your members to decrease annual costs, improve member health, increase member satisfaction, and boost member retention.

Do you need more in-depth information on these or other effective methods?

MedXM is a national leader in the design and implementation of preventative care technology. Contact us today to learn more about how we can assist you in achieving a five-star rating.

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