Industry Voices—Reaching for the (Medicare) Stars: Leveraging AI for better quality outcomes

Quality performance is critical to the success of any organization committed to value-based care (VBC). For health plans, accountable care organizations and other types of organizations that work with Medicare Advantage (MA), high Medicare Star Ratings are particularly important. Bu,t as the numbers show, there’s a big difference between knowing you need a high rating and actually managing to achieve it.

Fortunately, some specific steps can make a major difference. And, with the emergence of technologies such as artificial intelligence and natural language processing, organizations looking to improve have new and powerful tools at their disposal.


Medicare Star Ratings: What’s at stake?
 

Every year, the Centers for Medicare & Medicaid Services (CMS) uses its Star Ratings system to assign scores to health plans and other healthcare organizations working with MA and Medicare Part D. Each organization’s score is determined based on its handling of various defined measures of care, and it can have major financial consequences. A five-star rating is considered excellent, four stars mean that an organization is above average and anything below three stars is considered poor.

Once an MA plan is mature enough to be rated by the Star Ratings system, it must consistently earn at least four stars to get a 5% quality bonus payment and other benefits. Plans with at least 4.5 stars get higher rebate percentages, and those with a full five stars get benefits that can help them attract new members.

When a plan drops below four stars, the financial fallout can not only punish the organization itself but also ultimately cause a drop in the quality of patient care that it’s able to provide. That makes it especially concerning that average scores fell between 2023 and 2024, with 244 health plans dropping by at least 0.5.


Keys to improving Star Ratings: A three-pronged approach
 

When considering strategies to close care gaps and improve Star Ratings, it can be helpful to divide the measures that affect an overall rating into three categories: chronic condition management, post-event follow-up interventions and preventive care.

It’s important to perform well in all three of those categories. These steps can help:

  1. Improve chronic care management, including through annual wellness visits. Although care gaps for chronic conditions can typically be closed at any point during the year, it’s best to schedule annual wellness visits relatively early in the calendar year whenever possible. This can help avoid a rush toward the end of the year, which could put unnecessary pressure on practices. It’s also often helpful to have these visits early in the year because they can help clinicians identify care gaps that can then be closed over the course of the year.
  2. Improve post-event follow-up by streamlining the handling of patient information. Unlike chronic care management, the measures for post-event follow-up tend to be very time-sensitive, with some requiring that essential steps be taken within a matter of days following an event such as hospital admission or discharge. Documentation plays a critical role in post-event follow-up measures, making it especially important to ensure that hospitals, clinics and other institutions share information smoothly and reliably.
  3. Improve preventive care by identifying patients eligible for screenings and vaccinations, and by reaching out to them effectively. While physicians already typically use electronic health records that can automatically provide reminders for screenings and vaccinations, the fact that gaps in preventive care are so common shows that there is still significant room for improvement. For providers looking to enhance their outreach, omnichannel communication can help, allowing patients to receive notifications and reminders via phone calls, emails, text messages and other channels.


Cutting-edge tech for identifying and closing care gaps
 

To improve performance in each of these three categories, it’s essential to identify care gaps—a process that is often difficult, time-consuming and inefficient because of the need to sift through large volumes of data.

For health plans and physician groups looking to close care gaps, cutting-edge technology such as AI and data analytics offers more efficient ways to navigate these data. By analyzing patient records and other relevant data sources, they can help care teams identify opportunities intervene and close care gaps.

In addition to identifying care gaps, advanced data technologies can surface previously overlooked information that may impact care decisions, ensuring that unnecessary interventions are avoided or that important steps aren't missed. They also assist in improving documentation accuracy, which is critical in VBC environments.

As VBC continues to grow in the U.S., technology can make a powerful difference for any healthcare organization looking to improve its performance and achieve a higher Medicare Star rating. Even healthcare organizations that do not (yet) have risk-based contracts should plan to implement innovative solutions soon—allowing them to prepare before facing the pressure to adapt quickly to value-based healthcare models. Given the importance of identifying and closing care gaps, tapping into the power of AI is an essential step that can help healthcare organizations thrive in the world of value-based care.

Michael S. Barr, M.D., is a board-certified internist and the president and founder of MEDIS, LLC, a veteran-owned independent healthcare consulting firm. He was previously executive vice president at the National Committee for Quality Assurance. He is also a medical advisory board member for Navina.