U.S. Centers for Medicare and Medicaid Services (CMS) Star Ratings are critical to driving member retention and financial reimbursement. The higher a Star Rating is, the higher the reimbursement rate a plan receives.
In 2024, CMS changed the methodology for 2024 Star Ratings, including introducing Tukey outlier deletion when calculating non-Consumer Assessment of Healthcare Providers and Systems measures. This change improves predictability and stability in Star Ratings by removing outlier contract scores before applying mean resampling to determine cut points. The changes also added data integrity issues to the description of missing data in the disaster policy.
In addition, the Plan All-Cause Readmissions measure was added back in, and the Diabetes Care — Kidney Disease Monitoring measure was removed. The average Star Rating for plan all-cause readmissions was 2.9, medication adherence for hypertension (RAS antagonists) and controlling blood pressure were both 3.4, and customer service and care coordination were both 3.6.
Reducing hospital readmissions and improving medication adherence can help improve Star Ratings. One of the ways to do this is by improving innovative offerings, such as digital health solutions.
Reduce Plan All-Cause Readmissions
The Hospital Readmission Reduction Program was established in 2012. Under this program, hospitals with high readmission rates receive significant penalties. By implementing digital health solutions, hospitals can save money while improving patient outcomes.
According to the Kaiser Family Foundation, since the program’s beginning, 2,920 hospitals—55 percent of hospitals and 93 percent of general acute hospitals—have received at least one penalty. The program has been effective in reducing hospital readmissions and saved approximately $521 million in 2021 alone.
One of the most significant strategies to reduce readmissions and expenses is to implement a digital health program. This is beneficial for providers, payers, and members alike. Providers benefit from having a system for aftercare in place to avoid readmissions, and members who receive aftercare through a digital health program stay out of the hospital more than those who don’t receive aftercare through digital health systems.
Between January 2007 and October 2012, 1,708 health plan members were enrolled in a digital health study. The following results were found when using these digital health services to care for members with heart failure after they were discharged from the hospital:
- 23 percent reduction in hospital readmissions
- 11 percent cost savings
- 3.3 x ROI and reduction in all-cause hospital readmissions
Medication Adherence for Chronic Conditions
Digital health programs dramatically improve health outcomes, including by helping members adhere to their medication and treatment plans. These solutions empower members to understand their health and take action as necessary.
Through digital health programs, members have access to tools that help them take measurements, submit updates to their care teams, and receive important directions from their providers. Members can also track their progress while following their step-by-step care plans, which are managed by their providers.
This helps members feel more comfortable interacting with their care team. Members receive personalized care and have a comfort level with their providers that can make them more likely to share important health information and take steps to improve their health.
Controlling Blood Pressure with Digital Health Solutions
Hypertension is a common chronic condition, but only 1 in 4 adults has their hypertension under control. This has an impact on payers and members because chronic conditions such as hypertension often require hospitalization and can also be expensive to treat.
Support and interventions, such as digital care management programs, can help improve quality of life, lower costs, and reduce the risk of hospital readmissions. To determine the impact virtual care solutions have on members’ lives, we enrolled 450 people with uncontrolled hypertension in a study. We found that participants in our remote blood pressure monitoring study group had better blood pressure control than those in the study control group. Additionally, we found that these results persisted even after the intervention study period.
Virtual Care’s Impact on Customer Service
A critical component to attracting and retaining patients is your organization's ability to provide a consistently positive experience. Leveraging digital tools to provide enhanced virtual care allows organizations to meet the growing demand for healthcare and provide patients greater access to the care they need, leading to better outcomes.
Naturally, the more positive the healthcare experience is, the better the Star Rating. While that might seem obvious, it’s important to emphasize just how much the patient experience is built into the backbone of CMS Star Ratings.
According to CMS, there is essentially no way to maintain a four- or five-star rating without providing a highly positive consumer experience. More than 40 quality measures across five different categories contribute to the calculation of the ranking. The categories are:
- Mortality
- Safety
- Readmission
- Patient experience
- Timely and effective care
Healthcare companies that have earned five stars across the board have often put the patient experience front and center in their missions and marketing. For example, Cigna Healthspring of Florida attributes its five-star status to “incremental sustainable wins” and taking “a holistic approach.”
Cigna has a customer experience team that focuses on issues that directly impact customer satisfaction. When a healthcare company takes time to address challenging obstacles to providing exceptional customer care, the result can be a significant increase in its Star Rating.
Focus on Preventive Healthcare and Care Coordination
Although preventive care has been a healthcare buzzword for the last few decades, the Centers for Disease Control and Prevention reports that the use of preventive healthcare services is still disappointingly low. Approximately 45 percent of Americans have a chronic health condition that could benefit from preventive care, yet only 5.3 percent receive full preventive care.
When healthcare organizations take the proactive step of improving their preventive care outreach, members are healthier and happier. The results can be seen in Star Ratings.
Going back to the example of Cigna, when this healthcare organization provided additional preventive measures, more than 85 percent of its members benefited. Specifically, Cigna contacted existing members to advertise options for receiving preventive medication home delivery, plus it offered preventive digital care coordination.
This ensured customers not only had access to the right preventive medications but also understood how and when to take them properly. The company believes this is one of the many factors keeping its Star Rating high.
How to Reach for the Stars
A strong Star Rating is within reach for any healthcare organization. Now’s the time to implement the strategies listed above to ensure your ranking always stays as high as possible.
AMC Health can help. We’re at the forefront of a revolution in healthcare that includes virtual patient care, digital care management, and home care options that empower people. We offer a full suite of options that facilitate the efficient use of Medicare while maximizing healthcare resource management.
Schedule a quick 30-minute call with our experts to learn more about increasing your CMS Star Ratings through high-quality patient care.
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