Stars as a Protection Strategy

Speaker A: Welcome to this episode of Soaring to New Health, focused on evolving the healthcare experience for our people, our communities and our clients. Whether you work in the healthcare industry or are a client or friend of Prospire, you're sure to learn something new when you tune in. This podcast series will cover a wide range of topics, from health disparities and how to address them to the latest regulation changes and how to navigate, um, them, to the future of healthcare and how it affects your organization.

Speaker B: Welcome back to season four of M Soaring to New Health, where we focus on what actually works in health care and why execution is the differentiator. I'm, um, Chris Mladenovich with my co host, Dan Krogan. Today we're talking about a shift in Medicare Advantage stars, why chasing higher scores is becoming a losing strategy, and why in 2026, protecting performance is what separates plans.

Speaker C: Joining us today is Bill Raybaugh, vice president of Government Quality at Highmark, bringing the health plan perspective, and Andrew Bell, who leads our government programs practice here at Prospire. It's great to have you both.

Speaker B: So, uh, I've been so excited to talk about STARS with you, Bill. Uh, but before we do that, tell us about your role at Highmark and big Picture, what you're seeing in stars.

Speaker D: Sure. Well, first of all, thanks for having me. I'm always excited to talk about stars. As vice President of Government Quality, my team and I have accountability for the overall star rating at Highmark. And as you know, that encompasses a, uh, multidisciplinary approach to managing programs, both internal and external to, uh, the company. So clinical programs, network provider relations, health plan operations, customer service, member engagement and satisfaction and the like. So think of my team as the group that's bringing it all together. So we as an organization walk in the same direction towards those four plus star objectives. Obviously, in order to be successful in stars, you can't just isolate it to one individual team or one individual group. It truly takes the entire organization working together. So we have the privilege of looking at the data, understanding where the risks, the opportunities are, and then collaborating with our partners across the organization, across the network, to ensure that we have the right strategies in place, the right activities. That's, um, what we've been doing year in, year out, um, and have had great success in that. So we are at a very interesting inflection point with STARS right now. The pace of change is accelerating, uh, with no end in sight. I've been working in stars for over 12 years now, and we've always said it gets harder each Year, and you have to really embody a spirit of continuous improvement. Um, but the pace at which you need to improve has, uh, really accelerated within the last two to three years from the standpoint of making sure plans are staying at the front of the curve. Right. So that blocking and tackling type of approach to drive additional care gap closure, to drive optimal cahps survey scores, HAAS survey scores, you know, appeals, and all of the operational plan oriented metrics. But with the recent shift now where a lot of those operational measures are going away and the focus is really on health outcomes and clinical performance, that's really where plans need to be orienting their attention to, uh, stay at the front end of that curve. So it's an exciting time, uh, but obviously a time that warrants a shifting in strategic focus and, um, newer and better initiatives to hit that.

Speaker C: Bill, thanks so much for that perspective. Uh, Andrew, from your seat, what are you seeing going on with the Medicare STARS program right now, uh, across the plans? And where are you seeing some of the struggles?

Speaker E: Yeah, what a wild, wild year, year and a half we've seen here in the world of stars. Um, I think my short answer is that the Medicare STARS program is in the middle of a fairly significant reset and recalibration. You have cms, you have medpac, you have think tanks like the Paragon Health Institute who have talked for a while about how the STARS program is in real need for change. Uh, there are too many procedural measures, there are, uh, too many operational measures and not enough outcomes focused measurement. Well, CMS directly address that. In the 2027 final rule, they removed 11 measures, again mostly administrative in nature. So on its face, the program has changed a ton in terms of just what plans are being measured on. Taking sort of a broader view in the landscape. STARS is about to shift. Given these codified changes from the 27 to, from the 27 final rule between Staryear 27 and start year 29, some of our internal projections and estimates indicate that, uh, the weighted enrollment average, uh, star rating will decline by almost 25 basis points just in totality. Um, and those declines are going to translate into fewer contracts receiving quality bonus payments, uh, especially because plans typically over overperform in those administrative measures. Uh, so it's going to force a lot of plans to readjust their math behind the scores. Uh, uh, you know, from, from where they have been to where they should be in the future. I'd end just by saying, uh, there is no end in sight here. Um, the evolution of the STARS program is far from complete. There are many areas under consideration. Things like changes to measure weights in the future, potentially, uh, auto enrollment into Medicare Advantage, as some have, uh, discussed at the federal level, uh, there will be more than likely more outcomes driven measurement. Um, so STARS as we knew it is not going to be STARS as we know it in the future.

Speaker B: Bill, you brought up the multidisciplinary approach that it takes to really be successful in the programs. And I remember 12 years ago working with you, and that was probably the hardest thing to do because everybody in some way works in a silo, and breaking down those walls is hard. Has it gotten any easier?

Speaker D: Well, it's funny, Chris. Um, I'd say with stars, anybody that has worked with me for a long time knows I like to say you never really get there. You never cross the finish line. Right. There's always work that needs to be done. Because when you look at, uh, the priorities of a health plan, the landscape is continuously shifting, the priorities are continuously shifting, the risks are continuously shifting. Yet STARS is always there. So from my perspective, when you talk about that cross functional coordination, org design changes, leaders come and go, um, maintaining relevance, ensuring that STARS maintains its relevance within those organizations is critical. And that falls on the shoulders of the quality team to continue to educate, re. Educate, explain, bring the star, um, learnings, objectives, points of intersection to the leaders and the teams that are ultimately responsible for delivering on some of these initiatives and ensuring that they understand the role that they have to play and then they are informed, they have the insights, they have the data, and they have the support. Right. In order to pull that off. So I think of it less as breaking down silos and more of ensuring that everybody understands that they have a role to play and what that role is. And oftentimes that just takes continuous communication.

Speaker C: We talk a lot about change with what's recently happened, final rule, and some others that you both discussed. But, Bill, as you mentioned earlier, it's continuous improvement with stars no matter what. Um, from your seats and from your team seats. What kind of fatigue do you typically have to get through? Uh, or some of the challenges that come with that continuous improvement mindset.

Speaker D: There is the star's fatigue around the narrative that, hey, if we don't do this, we're gonna fail. Um, but I would say that is an evergreen risk, right. If complacency leads to failure ultimately. So you need to maintain that edge. The trick is truly guiding people along that journey so they understand enough to say, okay, this is the reason why, um, it is so difficult to maintain strong performance. Year after year. So I always view my role as part educator to the enterprise. It's one thing to go into the weeds on stars and you could talk about cut points and methodology changes and measure weights and things flipping to the display page and all of that STARS jargon. But I find a key to success is being able to push UM through that and package it in such a way that resonates with UM folks and that helps alleviate some of the star's fatigue. Where it boils down to say, okay, look, we know that if we just stay flat in this area, well, the cut points are increasing. So that 1 percentage point, year over year improvement might not be good enough if cut points are going up by two. Right. So it's explaining it in those simple terms that help, you know, maintain the sense of urgency, but also do it in a way that's relatable to the folks that you need to come along with you for that ride.

Speaker E: I think two quick thoughts, Dan. I think the first is accountability is incredibly important in stars. Uh, holding not only the STARS team accountable, but the broader ecosystem needs to be accountable for their particular slice of the STARS piece. And oftentimes I hear from clients, you know, I don't want to be the boy who cried wolf. And oftentimes you're dealing with such risk when there are tens or hundreds of millions of dollars on the line. One measure mistake could be the difference between a significant amount of quality bonus revenue or no quality bonus revenue. I think that really adds to the sort of feeling of fatigue that I'm seeing around the industry. I think one of the other, um, elements of fatigue that are, that are cropping up sort of in our day to day interactions with clients are around back to that theme of accountability. There is a fairly standard approach to a STARS model to include sort of measure level owners. You have someone accountable for a measure and I think for many years that model worked quite well. But over the last several months, maybe about the last year, I've started to think and wonder and question that sort of paradigm. When STARS is so highly matrixed at organizations, is it really fair to hold a single person accountable for the totality of a measure? When you have plan leaders thinking about things like crosswalking membership or reducing benefits or acquiring another plan or a major investment in technology or a, uh, shift in their pbm, Doing well in STARS is not a single person or a single thing. It is the complete totality of, of many, many things all coming together. And I think that that pressure that a lot of STARS teams Feel nowadays is really creating a significant sense of fatigue and burnout from a lot of quality teams that, that I, that I speak with and that I work with.

Speaker B: The final rule came out uh, not too long ago and it laid out a significant number of changes to the program. What uh, surprised you and what made you happy?

Speaker E: Yeah, maybe a little controversial but I was a little surprised about the retreat from the health equity index, uh, or the excellent health out for all. Um, now with that being said, I completely understand the retreat mostly from a risk mitigation perspective. So you know, what do I mean there? The EHO for all, formerly the Health Equity Index in concept is a really good measure. It's designed to replace the reward factor bonus that a lot of higher performing plans receive. Uh, uh, and the retreat of the reward factor could likely save some money ultimately uh, into the system. But this excellent health outcomes for all measure was also created in order to really incentivize plans to focus on high need populations, uh, such as those LIS eligible members or the dual and disabled populations. And again it's no surprise that it's these exact populations that are often the most underserved, uh, the most uh, inadequate in terms of access to care and they also cost the most, they have the most medical burden. Um, and you know, CMS through the development of this measure I think was really seeking to create a vehicle to incentivize plans to pay more attention to those subpopulations of measures. Now with that all being said, there was heavy industry lobbying, there were a lot of loud voices on LinkedIn that I saw as it relates to this measure and CMS backed off, they didn't codify the change and they brought reward factor uh, back into the equation. You know, if adopted, as I alluded to, I think the EH overall would have certainly reduced overall STARS performance. It would have saved money in the form of reduced qbps and it would have fundamentally sort of rewritten the STARS math game, uh, which, which would have shook up a lot of different plans. Now sort of in as I kind of summarize all this, it's my view that the administration really decided against this action, most likely for a litany of reasons but, but probably primarily just to mitigate the risk of litigation. Um, there have been a number of plans who have pursued sort of a uh, litigation strategy against STARS degradation. And as constructed, sure the measure was a little messy. Was it well intended? Yes. Was it well crafted? Maybe. But I think the risk of litigation probably feared was a fear of CMSS and ultimately pulled back from the measure entirely. That's also likely why you're seeing a lot of these administrative measure, uh, pullbacks. Because it's felt like every year for the last several years someone was in litigation with the federal government surrounding the TTY FOI measure.

Speaker D: I like the direction in which we're going and you know, I was pleased with some of the tenets of the rule because with the elimination of the, uh, EHO for all, well intentioned as it was, I think it now positions plans to really focus their efforts in the areas that are ultimately going to be better for the members at the end of the day.

Speaker C: And with that comes a lot of pressure, uh, pressure to perform in your experience. Um, what's the instinct been whenever that changes happen and there's performance pressure, is there instinct to do more? And then how does that impact finances and uh, across the org, the instinct

Speaker D: is yes, always to do more. Um, I think most of us in this industry were wired that way. Right? Um, we realize there's always something more to be done. Uh, but I do think the best plans, um, are the ones that are able to take calculated risks, but also know when to say this program, this initiative, this intervention is probably not truly moving the needle and therefore we need to take a step back. And I think we'll continue to see that, uh, especially as the stakes get higher and the bar gets higher each and every year. You can't just add on more investment, more programs, more things, because then you'll implode under your own weight. So constantly interrogating, and that's where it's really exciting to look at. Advanced analytics, AI, all, uh, you know, really getting a hold on your data to look at these programs and understand which ones are truly moving the needle, which ones are making the difference and which ones aren't, and being able to shift your portfolio accordingly. I don't think plans can be successful without that mindset.

Speaker B: In the context of all the improvement strategies that the health plans have to take on in the STARS domain, uh, when do they start to break down?

Speaker E: I've been really fascinated, I think for some time around this sort of what I'm observing as sort of a natural dichotomy between star leaders who are influencers and star leaders who are innovative. And I think you can think about sort of interventions and tactics breaking down along sort of those lines. Is a star leader not influencing their peers, kind of working within the matrix environment well enough to sort of usher along an initiative or a tactic or a program, uh, to see it to fruition. And to see the investment sort of, you know, come to. On the other hand, you have those star leaders who are really on the forefront of action, who are looking at every different new solution out there and sort of challenging paradigms. And um, there's certainly a lot of, a lot more risk associated with that. As you know, you're probably gonna have to pilot a lot of initiatives and some tactics may not work initially, but if you sort of box your performance, we want to achieve X goal by Y date. Um, I think that would really incentivize sort of innovative thinking and um, potentially quick improvement on measures. Um, but overall, again, just from a, as tactics breakdown, as interventions break down, I think you sort of have to look at it through the lens of are you influencing the right partners internally? Uh, did you invest enough to see it to come to fruition? Uh, or uh, was it just really not well thought out at the beginning? And did you not sort of parameterize your uh, conditions well enough at the onset?

Speaker B: What have you seen in uh, practice and where are you on that spectrum?

Speaker D: I would take a little bit of a hybrid approach to that because I think influencing is absolutely critical as a STARS leader. Right? And through that influencing that can drive the innovation, not necessarily from the STARS team themselves, but from the multitude of other players that you need along for that ride. So I view, if you ask me, Chris, I think the number one attribute of an effective STARS leader is frankly the art of storytelling. We are drowning in data. And you can cut stars data so many ways, right? And you can have reams upon reams of reports with measures and cuts of membership and attribution and where it all sits and you put it in front of somebody that doesn't eat, sleep and breathe stars every day and they'll go cross eyed, right? So it really is incumbent in order to be effective, in order to influence, in order to spur that innovation. The most effective STAR leaders need to be able to weave together that narrative in ways that people are going to digest. Star leaders that take that responsibility in ensuring that those narratives are clear, are fresh, are relevant, are repeated constantly and ingrained. Those are the ones that help really spur innovation, not only within their own group, within uh, the STARS team, but across the entire organization.

Speaker C: Andrew, in your experience, how different is it running, uh, the strategy for health plans that are in four stars and trying to stay, stay there versus one that's trying to get to a four star?

Speaker E: I think from our perspective, you really have to take the plan's current state into consideration when thinking about any improvement Strategy or maintaining strategy in stars. Is the plan seeking to grow? Are they looking to make strategic investments? All of these bigger and broader considerations at the plan executive level really have significant impact to the overall star rating. If you're growing membership super quickly, the tactics and strategy to move you from maybe a three and a half to a four are going to be a little bit more difficult and a little bit more narrow than if you're at a steady state and you're already a four star and you have stable population of members and you're not doing too many wonky things with your benefits. So to sort of address your question, it really depends on what the plan is doing from a, uh, strategic executive level position. Um, it always comes back to data. Plans need to have accurate, uh, accurate data, uh, quick insights into certain cohorts of membership. You, uh, need to have the right partners in place, um, and you need to have a viable path, math path forward, uh, to achieving your target.

Speaker B: So guys, what is the one capability plans need to build now if they want to stay competitive over the next couple years?

Speaker E: Yeah, you know, one of the biggest areas of concern from our clients, uh, presently has a lot to do with HEDIS modernization, uh, and broader clinical data acquisition and management. You know, we live in a very disparate and unorganized clinical data world. Um, I know that there are new sort of native FHIR systems that are growing and there's new, uh, requirements from the federal government in terms of data standardization moving towards a CQL FHIR world. Um, and that's all great, but at present it's still quite a messy one. Uh, clients are asking us more and more about how should they be thinking about HEDIs, you know, modernizing your supplemental data capture, modernizing your acquisition strategies, and ultimately how do you manage and manipulate data to conduct analyses and really understand at a measure level what's driving performance up, down or sideways. And HEDIS as a function is fundamentally changing. What we knew of HEDIS 10, 20 years ago is most certainly not going to be what HEDIS is next year, the year after, five, ten years down the road. Um, the shift also comes on the heels of a lot of health plans having a lot of staff trained in sort of a HEDIS world that again, doesn't really exist, uh, in the future. And so a lot of clients are asking us to help sort of reimagine what HEDIS looks like in the future. What does a digitally, uh, measured sort of world look like? Uh, and it's been really fun to sort of help people Think through that future, help them reimagine um, their teams, help them think through interesting investment, uh, ideas. And I think from an overall capability perspective, modernizing your uh, HEDIS function is going to be a real game changer for plans.

Speaker D: I couldn't agree more. I'd say certainly on the infrastructure side, readiness for fire interoperability and the DQM mandate, that's table stakes. The shift in the elimination of the HEDIS hybrid methodology that is going to fundamentally change um, the landscape in stars. Because if you think about how measures are scored for the hybrid measures, you're only scored on 400 members each and every year. Whereas depending on the size of your plan that could be tens of thousands once the hybrid methodology goes away. So to that point, optimizing clinical data feeds, EMR extracts the proficiency of CPT2 codes to ensure that all of that is flowing into a plan's HEDIS engine. If plans aren't focusing on that now and getting ready for that, they will incur a significant decline when blood pressure and blood sugar shift to the ECDF's methodology in a few years. I'd say all of those are absolutely critical, important, but I also view them as kind of table stakes, investments and focus areas. The real differentiator is going to be doing all of those things, but then finding the insights in the data and driving whole person care, right? And being able to link the team of clinicians, whether it's primary care, whether it's specialty, whether it's third party vendor, to ensure that the health plan can truly be that linkage across all of those areas. So we know exactly in real time when you know when a blood pressure goes out of control and then what is the next best action? How is the health plan engaging that member, how is the health plan getting that member to heed the call to action, to go seek that care? How is that message going to be transmitted to the primary care or the care team to ensure that they have insight into the fact that um, this blood pressure, whatever it is, went out of control and they have the right tools, data, insight sites in order to get that member on a path to remediation. The plans that are able to do that, and that's a lot easier said than done, right? And doing so in a way that is time boxed, right? Because each and every year we're scored, I um, think those are the plans that are gonna be the most successful. It's kind of tying together the health outcome with the experience side and if you're proficient on both ends of those that is the recipe for four, four and a half stars in the future.

Speaker B: Andrew, you're out there working with a multitude of clients, and when you see a client or a plan doing well, what are they typically doing differently? What is that secret sauce that they're using?

Speaker E: I think number one, it's strong executive leadership. I think leadership from the top down who understand stars, understand the importance of the program, understand how to invest in it. Without strong leadership, um, you know, it's, it's very difficult to be successful. Um, and then I think second, second, it's that cross functional support that you get from your partners across the business. You need partners who are bought into the mission, vision and goals, uh, ones who understand your North Star, and ones who are willing to engage and excited to engage and then marshal the effort and energy of their teams to engage in STARS initiatives that will ultimately bear fruits toward the four, four and a half star performance.

Speaker D: Yeah, I think that, you know, having the buy in from senior leadership is critical, um, for a plan because ultimately you can't put STARS in a box and say, there's this one group that handles it. It truly takes the entire organization. But in order to execute upon that, right, you need the buy in, you need the sponsorship from your C suite and making sure that that message and those priorities are cascaded down to their respective teams so they know when they get the call that, hey, we need to partner on this, we need to lean in, we have a STARS opportunity that we need to capitalize on. Those teams inherently recognize that it's a priority and they will act. So I do think that executive sponsorship is critical to success.

Speaker B: Have we ever run into a, uh, situation where you had the executive sponsorship? They knew that the endeavor was quite important, but there was also another number one priority. How do you handle when an organization has multiple competing number one priorities?

Speaker E: Health plans have so many things that they have to deal with day in and day out. There's sort of yearly massive goals that they're all working towards. Success in Starz is one. Uh, I would love for that to be the only goal, but that is oftentimes not the case. Um, but, you know, in many ways, you can't achieve the litany of other things that you want to achieve without the revenue that STARS produces. And so it's hard to sort of rank choice some priorities, but without rebate dollars, without quality bonus payment dollars, it's really hard to offer things like interesting supplemental benefits or to grow into new counties. And so, you know, candidly, I would push back on some of those leaders who would challenge some of the priorities and say, look, you really can't achieve any of this unless you sort of start with the foundation of a strong STARS program and excellent scores to then drive and reinforce other priorities that you have coming down the line.

Speaker D: And I think it's also working with those areas to understand, well, what. What are their priorities? Because many times, you know, the spirit of STARS is executed in other capacities, right? Um, whether it's looking at total cost of care, looking at risk adjustment, A lot of the tactics are the same. So it's finding those intersection points to show that, okay, maybe our priorities aren't truly in conflict, they just need to be thought about differently or maybe measured a little more explicitly to ensure that you're capturing the STAR value versus, um, the other priority.

Speaker C: All right, new this season, we're going to go into the lightning round. Quick, uh, answers first, things that come to your mind.

Speaker D: All right?

Speaker C: Okay, Chris, you want to kick us off?

Speaker B: Favorite star measure the part C and

Speaker E: part D quality improvement measures.

Speaker D: A1C control.

Speaker E: Least favorite STAR measure any Haas measure.

Speaker D: TTY language line.

Speaker B: Biggest mistake plans will make in 2026.

Speaker E: Not truly thinking about their HEDIS program and what it'll take to be successful in the future.

Speaker D: Assuming we're going to get a break

Speaker C: in cut points, what's one thing average plans will get wrong?

Speaker E: Not Investing enough in stars.

Speaker D: Underclubbing clinical data.

Speaker B: Biggest risk performance in 2026.

Speaker E: Not having strong analytics to back up stars. Uh, tactics.

Speaker D: Weathering the market, disruption. And the continued change coming from cms.

Speaker C: One word for how plans should respond.

Speaker E: Leadership.

Speaker D: Intentionality.

Speaker B: And what's one thing that you would fix today if you could?

Speaker E: More, uh, direction from CMS about the future of the STARS program.

Speaker D: I'd like HAAS results sooner.

Speaker E: That's a good one.

Speaker B: All right, guys, let's bring it home. When you say stability is the strategy, what does that mean in practice?

Speaker E: Yeah, I think to me, stability as a strategy really comes down to leadership. It comes down to intentionality. It's strong, consistent leadership that provides clarity on the why on the so what? And the North Star for the organization. So every team, every function, every partner in your ecosystem understands how their work ties back to STAR success. You know, in practice, I think that shows up as a sort of m measured, well constructed work plan. You know, not just a set of reactive, disconnected interventions and random tactics. Um, and then maybe most importantly, it's about creating an environment where, you know, people aren't operating in silos. They're operating in a very strong matrix environment. Uh, they understand the expectations of their role, they understand what to, what to do every day when they show up at work, uh, and ultimately understand how their work does in fact impact the overall star rating.

Speaker C: Bill, what does that look like inside an organization that's doing it right?

Speaker D: It's bringing insights from data. Right. Ensuring that the insights then are actionable, are understandable, and are repeatable. When we think about how we manage our STARS portfolio, I view it as my job for everyone across the organization to know, where do we stand overall? Are we in good shape? Do we have challenges here? Where are they and why? And then the next step is to say, okay, if we do have challenges in certain pockets, whether it's a certain market or a certain discipline, what are the things that we, uh, have at our disposal today to remediate that and where do we need help? And being very clear around the things that we from the STARS team are pushing, but also where we need our partners to lean in and assist us in getting there.

Speaker B: And that's the shift. This isn't about chasing incremental gains anymore. It's about protecting performance in a more volatile environment because the margin for error is gone. Stability is the strategy. Thank you both so much for joining us today. If you're finding these conversations useful, follow Soaring to New Health so you, uh, don't miss what's next. Stay tuned for more of, uh, season four.

Speaker A: That concludes this episode of Prospire Soaring to New Health podcast. Don't forget to tune in to the next episode. To find more information on our hosts, guests or Prospire services, or to listen to previous episodes of the Soaring to New Health podcast, please visit www.prospire.com. soaring to new Health was produced by Prospire and Big Science pods. Please visit bigsciencemusic.com for more information.