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The CMS 5 Star Rating

What’s the deal with the CMS 5 Star rating?

Medicare 5 Star Rating

Every plan gets a score that represents that plan’s quality. It’s based on several factors like the quality of care, how responsive the plan is, patient satisfaction, access to care and customer service. Since the beginning of health reform law, it is used to determine how much a plan gets paid by Medicare for each member.

The rating scale is 1-5 stars, 5 being the best and 1 being the worst.

How is a Plan’s Score Determined?

There are 53 quality measures that CMS uses.  Thirty-six benchmarks are grouped into 5 groups (see below); the other 17 benchmarks have to do with pharmacy benefits.


I. Staying healthy: screenings, tests, and vaccines;

II. Managing chronic (long-term) conditions;

III. Member experience with health plan

IV. Member complaints, problems getting services, and improvement in the health plan’s performance

V.  Health plan customer service

Which Areas Can The Primary Care Doctor Affect?

Doctor’s can affect the first 3 areas which include prevention, chronic things like hypertension and diabetes, and ease of access to services. In reality doctors can influence these things by adhering to proven guidelines in managing these conditions and making sure they provide preventive screenings in a timely manner.

Why Should Doctors Care About the 5 Star System?

One of the main things about  the Affordable Care Act (ACA) is the focus on quality. The 5 Star ratings are an indicator on how well plans are performing.

The prevailing thought is that in the future payment to plans will move away from fee for service (FFS) to more of a performance- measured reimbursement.  Realizing this and improving patient care just makes sense.

What are some things that doctors can do right now?

1) Every year, on the member’s birthday, get them in for their physical, that way preventing and managing chronic conditions will be much more effective.

2) Every year, review all medication to prevent any adverse drug interactions. It will be a good opportunity to make changes to regimens. Members taking high risk medications can also be advised and given alternatives.  Really, this should be done each visit.

3) Allow extra time for members with 3 or more chronic conditions.

The CMS 5 star rating really accomplishes 2 things. It gives the plans incentives in the way of higher monthly payments to really provide excellent member service. It also serves as a guideline to prospective members as to what plans to consider and which plans to stay away from.

By Dave Wilson

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