Expert Advice from Dr. Jodi Smith, RN, MSN, ND, who has over two decades of Health Plan experience as a clinician and administrator.
The 2024 Star Ratings arrival brought with it feelings of overwhelm and uncertainty, as the number of 5-star health plans has significantly dropped compared to the previous year’s Star Ratings. But the impact goes beyond emotions. The sharp decrease in 5-star plans has resulted in over $1.5 billion in lost Quality Bonus Payments, affecting health plans’ profitability and market share.
Add on top of that all the changes to the rating system, and achieving higher star ratings can feel like a daunting mountain to climb.
One year medication adherence holds significant measurement weight and then the next HEDIS scores become the focus.
No matter how the CMS may modify the Star Ratings, health plans should remember that the real secret to success lies in their ability to activate and engage their members.
Plans that can do that well will be able to adapt to the ever-evolving healthcare landscape and rating systems.
At Virgin Pulse, we believe that it is these very challenges and changes that provide the necessary motivation for health plans to reassess their strategies and redefine the road to success.
We believe that differentiating yourself from the competition and achieving higher star ratings shouldn’t be an enigma.
And while we are not a health plan ourselves, as a digital health solution and health plan partner, for the past 20 years we’ve helped hundreds of payers improve on key metrics to increase their Star Ratings …
While these changes may seem daunting, the 2024 Star Ratings catalyzes a paradigm shift in healthcare quality assessment.
It challenges health plans to reach new levels and continuously look for more innovative ways to engage members and raise the bar to provide better care and value.
By responding to this call-to-action, payers have the opportunity to emerge as leaders in the industry for delivering improved services and true value.
Now more than ever, it is essential to maintain a committed focus on health and wellbeing throughout this journey to excellence.
So, in this article, we will provide you with three strategies that will assist you in more effectively engaging and activating your members and enhancing your star ratings for the measurement year 2025.
3 Strategies Health Plans Can Use to Excel in the 2025/2026 Star Ratings
Health plans aiming to seize this opportunity and strategically plan for the 2025/2026 Star Ratings should employ the following three potent strategies.
These strategies, which we’ll dive into in the next section, are designed not just to help health plans navigate the changes, but to easily continue to evolve with the continuous improvements CMS deploys for positive, proactive change.
- Enhance HEDIS scores
- Focus on closing care gaps
- Minimize Readmissions
Strategy 1: Conduct Targeted Outreach and Follow-Up Care to Enhance HEDIS Scores
Healthcare Effectiveness Data and Information Set (HEDIS) scores act as a performance measurement tool, enabling health plans to evaluate their performance and compare it with industry benchmarks. By precisely tracking and analyzing HEDIS scores, health plans can identify areas of improvement in care delivery, leading to better health outcomes.
One of the best strategies you can use to boost your HEDIS scores and as a result, your Star Ratings is to conduct targeted outreach and provide your members with proactive follow-up care Though many health plans recognize the importance of segmentation and personalize outreach, they often struggle to provide this experience to members – especially if they are only leveraging risk stratification data for segmentation and multiple vendors or tools for outreach. Members can be difficult to identify and hard to reach without the right data and predictive analytics platform. And without coordinated and compassionate outreach, and social economically sensitive interventions, it can be challenging for MA plans to build meaningful outreach strategies that lead to members’ acting.
To get even more specific and personal, using outreach methods catered to the individual members background such as ethnicity-specific messaging can increase engagement rates with the plan’s preventative and chronic care management.
Similarly, by facilitating proactive follow-ups such as timely reminders for routine check-ups or providing members with needed post-visit guidance, health plans can increase the odds that their members get the ongoing care that they need.
This sort of proactive approach underlines a plan’s genuine dedication to each participant’s health and wellbeing.
As your customers increasingly perceive you as a dependable partner in health, this good work and goodwill will also be reflected in the Star Ratings.
Client case study
Implementing this Strategy
An example of this strategy in action involves a health plan we worked with whose goal was to increase colorectal cancer screenings in a diverse population. To accomplish this task, we helped them to implement a highly targeted and multifaceted outreach strategy.
Ethnically appropriate, language-specific messages were sent through automated calls or follow-up letters to individual members. For instance, a male voice was used for outreach to Hispanic-Latino members, considering cultural nuances to improve communication effectiveness.
In addition, this strategy incorporated automatic transfers to a nurse line that was accessible 24/7 and barrier surveys to identify and address obstacles that could impede the uptake of screenings.
Outcomes of this Strategy
The results showed that this targeted outreach strategy was a resounding success, with a 56% overall improvement compared to the control group, representing a 3-percentage point HEDIS score improvement.
Moreover, there was an 89% improvement specifically within the Latino population who heard an ethnic-centric message with a male voice.
This case study shows how innovative and personalized communication strategies can significantly enhance preventive care measures, ultimately leading to improved HEDIS scores.
With more strategies of this nature, health plans can use the changes in the Star Rating system as a springboard to transform their current practices and elevate their service quality.
By adopting a personalized and proactive strategy of targeted outreach and follow-up care, health plans have an opportunity to move the needle in their performance, as measured by HEDIS scores.
This approach can carve a path for health plans to excel in the face of evolving Star Ratings and provide enhanced care to their members.
Strategy 2: Closing Care Gaps to Boost Star Ratings
Closing care gaps goes far beyond just filling the void in healthcare service delivery. It plays a critical role in improving health outcomes, enhancing patient engagement, and elevating overall plan performance, as reflected in HEDIS scores and star ratings.
While there are many different methods that can be used to tackle care gaps, one strategy that has proven to be effective is focusing on ensuring at-risk members receive the healthcare that they need. This strategy involves identifying your plan’s at-risk population segments and developing personalized outreach programs to encourage health screenings and preventive care for these members.
Real-world Example: Closing Care Gaps in Action
To show how this strategy can work in real life, let’s look at how a health plan client implemented this strategy.
The challenge that this health plan was looking to take on was to increase health screenings among at-risk members while also improving the star ratings for their Medicare Advantage programs.
To meet the challenge, we first helped the health plan to identify their at-risk population.
Once the target audience was identified, together, we developed multi-channel campaigns aligned with the needs of these at-risk members and the quality goals for each Medicare contract. These campaigns, executed through interactive automated phone calls and personalized mailings, targeted over 43,000 at-risk members, ensuring they were aware of, and had access to, the healthcare services that they needed.
This strategy led to significant improvements for the plan:
- 5-point increase in colon cancer screenings and
- 1-star increase across 10-star rating measures.
Impressively, these results were achieved within just 35 days.
This case study emphasizes the immense potential and effectiveness of focusing on closing care gaps for improving HEDIS scores which will lead to elevated star ratings.
By directing efforts towards helping at-risk members receive the healthcare they need, health plans can be more impactful in closing care gaps, driving superior health outcomes and achieving higher star ratings.
Strategy 3: Reducing Readmissions through Patient Engagement and Medication Management
The third strategy that health plans can use to prepare for the 2025/2026 Star Ratings is to focus on reducing readmissions through patient engagement and medication management.
By emphasizing patient adherence to medication and promoting higher patient wellbeing, health plans can effectively lower readmission rates. It has been found that adherence to medication is associated with higher patient wellbeing.
Additionally, according to a study by Gallup, patients with high wellbeing are less likely to be readmitted within 30 days. Implementing patient-centered approaches, such as providing a thorough explanation of prescribed medications and engaging patients in post-discharge care discussions, can contribute to improved medication adherence and overall patient wellbeing, thereby reducing readmissions, and improving HEDIS scores.
Conduct Patient Needs Assessment
To effectively reduce readmissions, a comprehensive patient needs assessment is the critical first step. This process involves evaluating the individual’s health status, needs, and barriers to care, aiming to create a comprehensive care plan. A crucial component of this needs assessment is medication reconciliation and education, which ensures that patients are using their medications correctly and understands their therapeutic roles, thereby minimizing potential health risks and preventable readmissions.
Real-world Example: Improving Medication Refill Rates to Reduce Readmissions
The importance of active patient engagement and addressing medication needs can be illustrated through a case study focusing on medication refill rates. While the core focus of this study is on refill rates, it also underscores a broader principle: actively engaging patients and managing their medication needs is a highly effective strategy for reducing readmissions.
The challenge for our client was to drive up refills for diabetes, statin, and ACE/ARB medications amidst a strict year-end push for improvements. The goal was not only to encourage refills but also to educate members on adherence and overcome potential obstacles impeding timely refills.
In response to this challenge, we helped them to identify 78,000 members who were prescribed multiple daily medications and had a primary care doctor (PCD) rate between 65% and 80%.
These members were then targeted for personalized outreach campaigns that included medication adherence education. Each member was provided with detailed information about up to three of the medications they were taking.
In addition, the campaign included personalized barrier-breaking tips designed to spur members into acting and refilling their prescriptions promptly.
The Remarkable Results
This strategic approach that we took with our client delivered stellar results.
The fill rates for those contacted in the campaign showcased an impressive improvement – as much as 25%.
Even more strikingly, there was an 85% improvement in refill rates among those who interacted with the campaign compared to those who didn’t.
In terms of star ratings, the campaign led to a 1-to-2-star improvement across medication categories, reflecting the significant impact the campaign made on patient engagement and medication adherence.
The success of this strategy highlights the importance of personalized engagement and effective medication management in reducing readmission rates. By carefully identifying patients’ needs and developing targeted outreach initiatives, health plans can foster medication adherence, improve patient outcomes, and as a result, increase HEDIS scores and star ratings
Seizing the Opportunity Hidden in the Challenge
The shifts exhibited in the 2024 Star Ratings bring both challenges and opportunities for health plans.
And while it might be overwhelming to experience a drop in star ratings and the complications of adapting to a new rating system, these changes also provide a fresh perspective for health plans to differentiate themselves in a competitive space.
At Virgin Pulse, we believe that through these challenges, health plans can identify and adopt innovative strategies aimed at achieving higher Star Ratings.
We believe that the evolving changes in Star Ratings should very much be perceived as a springboard for health plans to reassess their star program strategies, redefine success, and strive for continuous improvement.
Three such strategies to help accomplish that include enhancing HEDIS scores, focusing on closing care gaps, and minimizing readmissions.
By maintaining a strong focus on members’ health and well-being, health plans can not only cope with the changes but also leverage them, aiming for the continuous delivery of improved services and lasting value to their members.
Learn more about how to increase your star ratings, watch our recent AHIP webinar.
If you’re looking for a partner who can help you create a personalized game plan for increasing your 2025/2026 Star Ratings, connect with a health plan expert.
Remember, the shift in the Star Ratings system doesn’t have to be a disruption; instead, it can be a powerful impetus for health plans to emerge as stronger, more agile, and more responsive leaders in the healthcare industry changing lives for good.