STAR/HEDIS Quality Optimization

STAR Quality Optimization Model

Customer Business Goals:
  • MA plans are under intense revenue pressure with reductions in reimbursements
  • Reclaim the revenue loss with higher STAR Quality Rating
  • Plans can receive 5% additional reimbursements if they improve from 3.5 stars to 4 stars, which equates to $40 PMPM or an estimated $7.5M annually
  • Once 4 STARs is achieved, this solution will help maintain the current rating and accelerate towards the next level STAR rating
  • Higher rating helps in marketing, branding, and expanded benefits to market throughout the year
  • Increase market share

A web based application that utilizes a Predictive Optimization and Prioritization Model for identifying, prioritizing and performing member outreach to improve quality scores.

The optimization algorithms analyzes customer population and the current STAR performance and determines the easiest path to get to a target score (4.0 / 5.0) over the next 12 months.

itreosHealth then develops predictive models for each targeted STAR quality measures to identify members who are likely to be non-compliant and are loaded into the Quality Optimization Digital Outreach Application for use by the Quality Outreach team.

The solution includes predictive prioritization of the STAR quality measures that are likely to have the highest impact to the current calendar year’s STAR rating. These targeted measures are subject to change at any time.

  • E.g. For calendar year 2017, customer may have identified three quality measures that are to have the highest impact in STAR ratings:
    • D12: Medication Adherence for Diabetes Medications
    • D13: Medication Adherence for Hypertension (RAS antagonists)
    • D14: Medication Adherence for Cholesterol (Statins)
  • For future years, there may be different measures based on the comparative market performance and the membership

Scorecards will be provided monthly for ongoing performance tracking and monitoring.

  • VitreosHealth provides monthly gaps-in-care insights and expected STAR performance scores based on the Outreach and Gaps closure for the three measures