July 12, 2022
The Role Interoperability and FHIR Play in Improving STAR Ratings

Everyone is looking to the stars for advice these days, it seems. We’re consulting the celestial bodies on the foods to eat, places to stay, and things to buy. And now, we’re turning to STARs for advice on where to get healthcare and health insurance.

This growing reliance on evaluating metrics is no secret: If a place, product or service doesn’t have a high enough star rating, it’s immediately considered suspect, leading to lost customers and reduced profits.

The same is true in the healthcare industry. A poor Star Rating can strike a blow to the core of a health plan due to the implication of low-quality patient outcomes. Not only will it be hard for them to gain new members, but health plans with low Star Ratings miss bonus reimbursements, pay penalties, and have a harder time attracting quality providers. Even worse, consistently low ratings could cause a plan to be removed from Medicare altogether.

On the other hand, high Star Ratings lead to increased enrollment and revenues, bonus payments, and rebates that can be passed on to members in the form of extra benefits like reduced premiums or expanded coverage. Those benefits lead to greater member retention, which results in even higher Star Ratings, more bonuses, and better payouts. 

The profitable cycle attached to a high star rating is why every plan should strive for a positive assessment of its services. That being said, how is a high Star Rating achieved? And is all hope lost for plans who suffer the consequences of low Star Ratings, or can something be done to improve them?

Let’s Get the Basics Out of the Way, First:

Star Ratings are issued by the Centers for Medicare and Medicaid Services (CMS). Their objective is to provide a comprehensive assessment of Medicare Advantage plan’s to help patients, families and caregivers to make more informed choices regarding their healthcare services. To earn a high star rating, the plan must meet certain criteria across several domains that include patient health maintenance, member experience and complaints, chronic disease management, and customer service.

Whether high or low, Star Ratings directly impact the plan’s bottom line.

Impact of a High Star Rating

• Increased payment from Medicare to payers and providers
• Increased rebate on premiums
• Increased enrollment, driven by patient confidence
• Improved provider recruitment and retention
• Increased revenue

What a Plan With a Low Star Rating Looks Like

A plan can earn a low Star Rating (three stars and below) for a plethora of reasons.

Plans earn two stars (or less) when, over the course of a year:

• Less than 50% of its eligible members received a mammogram 
• Less than 68% of its members improved or maintained their physical health
• Less than 79% of its members received an annual flu vaccine
• Less than 90% of its members’ weight was checked 
• Less than 69% of its eligible members received an eye exam to check for damage from diabetes
• More than 28% of members chose to leave the plan

Low-performing plans can fall short in other measures, too, such as the speed with which they handle member complaints and appeals.

What a Plan With a High Star Rating Looks Like

High-performing plans excel in reporting and customer communication. They manage to reach a greater percentage of their members with preventative care and follow-up. Patients experience higher adherence to prescriptions, physical therapy, and more. Plans with high Star Ratings excel at providing Value-Based Care (VBC) and are rewarded.

• More than 85% of patients took diabetes medication as directed
• More than 97% accuracy in drug pricing information listed on their website
• More than 89% of patients in need of the service received TTY Services and Foreign Language Interpretation
• Average member rating of quality of care was higher than 87/100 

By Now, You’ve Likely Spotted a STARtling Trend: Reporting + Communication.

The Star Rating value system holds the function of reporting and customer communication in extremely high regard when conducting their assessments. The good news is that fixing a plan’s reporting and communication can be fairly simple. Sure, accurate reporting takes a lot of time. But it doesn’t have to. Since the key to improving reporting and communication is interoperability.

More about interoperability in a minute–you’ll see it plays an important role in improving Star Ratings with the changes CMS will implement in 2022 and 2023.

Further complicating matters for health plans and providers, CMS adjusts the measures they select nearly every year, with the goal of rewarding improved patient health. They change the weight each measure receives in the final Star Rating they award. Sometimes, they also move the cut-off point for achieving certain Star Ratings on specific measures.

Expected Changes to 2022 Star Ratings

Right now, the (celestial) stars aren’t telling us how CMS will update the entirety of its assessment process. However, we do know one key addition CMS will make in 2022: MIPS.

MIPS, which stands for Merit-based Incentive Payment System, was established by the Medicare Access and CHIP Reauthorization Act of 2015. It is largely responsible for pushing the healthcare industry from fee-for-service to pay-for-value. MIPS replaced the Meaningful Use program and promotes the exchange of electronic health information. 

Here’s where MIPS matters to our discussion right now: A subset of 2020 MIPS quality measures will be reported as measure level Star Ratings in 2022.

• Quality (30% of score)
• Promoting Interoperability (25% of score)
• Improvement Activities (15% of score)
• Cost (30% of score)

According to the Quality Payment Program (QPP), MIPS will continue to favor measures that promote interoperability, aiming to reduce the administrative reporting burden and focusing on improving population health and lowering costs for patients. 

(This article includes more in-depth charts and data points about the MIPS Promoting Interoperability Category.)

The Role Interoperability Plays in Improving Star Ratings

Promoting Interoperability (PI) will improve your MIPS score, which can improve your Star Rating. But PI can boost your Star Rating in other ways, too, because it results in:

• Better customer service 
• More accurate data collection
• Better care coordination
• Greater patient engagement

Interoperability will ease your reporting burden. It will simplify communication. It can reduce, and eventually eliminate, problems caused by data silos. As data can flow more freely, fewer errors will be made. 

Adopting greater interoperability measures means your providers can have more time face-to-face with their patients and less face-to-computer time. Ultimately, patients will have an improved overall experience and they receive more power to control their health information.

For these and many more reasons, we foresee that CMS will continue making rules to promote and incentivize interoperability. So let’s discuss how to best prepare for those inevitable changes. 

The best way to quickly achieve true interoperability is FHIR. (FHIR stands for ​​HL7’s Fast Healthcare Interoperability Resources standard.)

FHIR: The Road to Improved Interoperability

HL7® FHIR® is your shortcut to improved interoperability because it defines how healthcare information is exchanged between different computer systems, regardless of how it is stored in those systems. FHIR makes it possible for clinical and administrative data to be securely and rapidly sent, received, and shared by different applications and systems. Both providers and payers benefit from this two-way exchange of data with Medicare, Medicaid and Commercial payers.

Some Ways FHIR Helps:

✔️  Improved Reporting

Accurate, accessible reports are crucial for understanding which measures a plan performs well or poorly on. With FHIR, you can run your reports more easily and be confident in the data quality. You can identify opportunities for improvement and push performance metrics to stakeholders. FHIR keeps the important data flowing.

✔️  Improved Communication
Communication is what makes every relationship work–especially in healthcare. Patient satisfaction and engagement rates go up with better communication. FHIR can help track providers’ communication efforts and improve patients’ access to information. 

✔️  Care Coordination
According to the Agency for Healthcare Research and Quality (AHRC), ​​”well-designed, targeted care coordination that is delivered to the right people can improve outcomes for everyone: patients, providers, and payers.” Interoperability and FHIR is thus at the heart of good care coordination. 

Many EHR vendors will insist that they are FHIR-ready. However, this is only partially true. EHRs struggle with processing data from multiple sources. Even the best, most confident EHR needs a “data wingman” to help translate and share data. The best data wingman is an expert in FHIR who supports every one of its resources.

Improve Star Ratings by Improving Interoperability with FHIR

The measures CMS chooses to assess for Star Ratings will change every year. Anyone can try to predict the future, but only CMS knows which measures will change and by how much. This creates uncertainty that can throw any plan off balance. 

But you can count on one thing to stay the same: changes that CMS makes will be intended to improve patient quality of care and access to health information. They will do this by promoting and incentivizing interoperability measures.

To ensure your plan scores well on the Promoting Interoperability measures in both MIPS and CMS 2022 Star Ratings assessment, partner with a FHIR expert who has been there from the beginning. 

The right FHIR partner can help you improve and maintain your Star Rating, even amidst uncertainty, by making interoperability an easy win.

Get in touch with a friendly Smile expert today to learn more about our purpose-built solution.