Shaping a Company That Moves the Needle in CMS Star Ratings
Leading a business is always challenging, but building a product that improves the health decisions of millions is even harder and requires clear and focused goals.
Over the years, working closely with health plans, we’ve learned that defining ‘success’ in CMS Star Ratings is more complex than it seems. Navigating evolving priorities and conflicting goals helped shape MedOrion’s product and business strategy. In this article, I’ll take you behind the scenes of how we tackled these challenges.
Looking at the Bigger Picture
Our early work with health plans started with just one or two quality measures. The scope was clear, and the goals were straightforward. But generally speaking, success in CMS Star Ratings is about much more than that. In fact, it is often misunderstood as simply advancing a specific measure to boost the total score.
Focusing all your efforts in one place means other measures will likely remain overlooked. Measures the health plan didn’t focus on because they had already reached a top star rating or aren’t perceived as a current CMS focal point might turn into problematic blind spots.
Today, some of our customers track nearly 20 measures, highlighting different issues, such as conflicting internal priorities, as different teams within the same organization often have competing top objectives.
For example, the pharmacy team might push for higher medication adherence, while the HEDIS team focuses on clinical outcomes. This realization led us to develop governance tools that allow organizations to better align priorities and form data-driven strategies that can be shifted mid-year. MedOrion’s platform features an analytics dashboard that helps identify which measures to prioritize based on their impact and current goals.
Consistently maintaining strong ratings is often more challenging than achieving them in the first place. Success is built from gradual, behind-the-scenes efforts that remain hidden while educating members and forming long-lasting, solid relationships built on trust.
This became clear when it was time for our very first contract renewal. Instead of producing quick wins, we planned for deeper, more meaningful future achievements. Rather than focusing solely on members close to meeting a goal, our technology helps health plans invest in those who may take longer to engage but will drive sustainable improvements. We’ve seen cases where outreach didn’t yield immediate results but led to significant behavior shifts over time.
Be Everywhere, Not All Over the Place
On the one hand, health plans address many members and measures. On the other hand, health decisions are individual by nature and require tailored, specific interventions. How can health plans address this contradiction? For this and similar reasons, MedOrion’s quality improvement management platform is all about operationalizing data-driven interventions.
The answer is combining a holistic approach that examines every factor with the ability to “zoom in” on each barrier using tailored messaging. MedOrion’s Electronic Behavioral Records (EBR) technology takes into account countless factors to reveal what each member needs, while automation allows us to approach every member effectively. Our validated content library and communication tools ensure these efforts are personalized, relevant, and impactful.
Adapt to Change
CMS guidelines evolve yearly, with standards constantly rising, making achieving 5-star ratings increasingly difficult. However, CMS requirements are not the only thing that changes. Quality measures evaluate human behaviors, and real-world changes influence members’ decisions.
Members might stop taking their medication after having done so for a long time. We’ve seen that happen more than once. Investigating the reason behind the shift in adherence is what allows us to address it and get members back on track.
Data may show that many members of a similar background changed their behavior simultaneously. Then, combined with the health plan’s records, we spot what caused the shift. For example, the decision to close a nearby pharmacy created a logistic barrier that negatively impacted medication adherence. This means that distance is a substantial barrier to address, and sending messages regarding available transportation and delivery options would be a smart move in terms of ratings. Identifying the root cause is the key.
Success in CMS Star Ratings requires a proactive, adaptive approach that addresses changing member needs. Tracking member behavior and the logic behind it throughout the entire health journey enables us to prioritize interventions that improve health outcomes and align with key quality measures, and the plan’s strategy. From my experience, success is neither a sprint nor a marathon. It’s a continuous journey, shaped by the people we work with and the lessons we learn along the way.