Health Plan Improves Quality Scores with Freed Guidance
Freed Associates helped a national health plan improve its CMS Quality Star Ratings by two stars in just two years. Learn how breaking down silos within the organization and providing user-centered recommendations lead to measurably improving the health plan’s scores.
Understanding CMS Quality Star Ratings
Centers for Medicare & Medicaid Services (CMS) established a quality rating system for every participating health plan in the exchange marketplace to help consumers make more informed healthcare decisions, create oversight of health plans, and provide actionable information to health plans to help improve the quality of services.
An extensive national health system engaged Freed Associates (Freed) to help create a strategic plan to improve its Clinical Quality Star scores measurably, avoid costly penalties, and increase market share.
The Freed team assessed operations, provided recommendations for improvement, and set a strategy that put the health plan on an ambitious trajectory.
The Importance of Organizational Alignment in Transformation Projects
The first step to helping the health plan improve its quality scores was conducting a landscape assessment to understand and align on the current issues impacting CMS Star Ratings. At the beginning of any major transformation project, it’s critical to establish a shared understanding of the situation and align on where all involved parties are headed. During the landscape assessment with a representative team of stakeholders, Freed focused on four key opportunity areas: accountability, operations, strategy, and data.
The Freed team quickly discovered that the health plan’s quality teams operated independently and were not leveraging the plan’s resources to bolster its quality program. The health plan had a wealth of expertise, tools, and data to support quality interventions, but these were not utilized to develop market-specific solutions that could improve quality scores.
Targeted and Actionable Steps for Improving CMS Quality Star Ratings
Freed’s approach included three steps to help get the health plan on the path to improvement.
Step 1: Build a Foundation for Necessary Collaboration.
To unlock the expertise already existing within the health plan, Freed outlined and proposed a new organizational structure that strengthened internal relationships and leveraged additional resources to support quality initiatives. As with any organizational transformation, this was easier said than done. It included breaking down existing silos and making sure that resources had clearly defined accountabilities and responsibilities across the Enterprise and local markets.
Step 2: Create Structures to Enable Long-Term Quality Improvement.
Next, Freed helped establish a Clinical and Operations work group for Healthcare Effectiveness Data and Information Set (HEDIS) measures. This team was empowered to facilitate ongoing change management, identify holistic solutions, and foster partnerships across the system.
Step 3: Actionable Recommendations to Hit the Ground Running.
Time was of the essence. After understanding the challenge’s landscape and identifying goals, Freed helped the new team prioritize actionable steps that could be completed in six months.
Freed’s actionable recommendations included conducting a population analysis to understand plan membership fully, prioritizing select clinical measures, establishing target goals, supporting improved network engagement, improving member outreach programs, and streamlining real-time feedback with the internal project teams. Progress was continually monitored to help build and maintain momentum, key accomplishments were shared, and big wins were celebrated along the way.
Fostering a Culture of Accountability, Collaboration, and Innovation to Achieve Higher CMS Quality Ratings
The health plan saw impactful results by integrating quality teams, establishing effective quality improvement processes, and implementing targeted recommendations. The health plan increased its star ratings by an entire star in the first year and is on track to continue quality improvement. The journey is not just about hitting the numbers; it’s about fostering a culture of accountability, collaboration, and innovation. The health plan is now on track to operate with a clear, strategic vision, leveraging data and expertise to drive quality improvements. The sustainable plan ensures that it can adapt to future challenges and continue to enhance patient care.
Freed Associates’ involvement went beyond recommendations — empowering the health plan to realize its potential and equipping it with the tools and frameworks needed for long-term success. This case study is a testament to the power of strategic alignment, dedicated teamwork, and actionable implementation support in transforming healthcare quality. The health plan’s remarkable turnaround indicates what can be achieved with the proper guidance and a commitment to excellence.
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