CMS Star Ratings – A Step towards Better Healthcare Coverage July, 2013 BLOG POST
Overview The Center of Medicare and Medicaid Services (CMS) created a Five-Star Quality Rating System for Medicare Advantage (MA) plans to compare MA plans more easily with focus on improving in the areas of safe, effective, patient-centered, timely, efficient and equitable healthcare coverage. Also, considering factors such as; improving the individual experience of care, improving the health of populations and reducing the per capita costs of care for population. CMS’s mission is to raise the importance of quality for Medicare. The current Star Ratings measures span five broad categories: • Outcomes – measures that focus on improvement to a beneficiary’s health as a result of care that is provided • Intermediate outcomes – measures that concentrate on ways to help beneficiaries move closer to achieving a true outcome • Patient experience – measures that represent beneficiaries’ perspectives about the care they receive • Access – measures that reflect processes or structures that may create barriers to receiving needed health care • Process – measures that capture a method by which health care is provided CMS uses the Star Ratings to inform beneficiaries about the performance of their available plans on the Medicare Plan Finder website, as well as for the basis of Quality Bonus Payments (QBPs) for MA organizations. Medicare Advantage enrollment grew by 10 percent in 2012, exceeding 13 million enrollees nationwide, a 27 percent of the total Medicare population – according to the Kaiser Family Foundation. About 2,000 plans exist, however fewer than two dozen are available in any given location.1 Medicare Advantage plan enrollment has grown by 28 percent since 2010, and the CMS anticipates that it will continue to grow by another 10 percent next year.2 The federal government, as well as brokers like PlanPrescriber.com, has online tools representing the ratings of Medicare Advantage plans. Moreover, many seniors may encounter the ratings in the process of researching and enrolling in a plan, increasing the likelihood that the ratings will factor in enrollment decisions. Star Ratings Cover 9 Domains Ratings of Health Plans (Part C) Staying healthy: screenings, tests, vaccines Managing chronic (long-term) conditions Member experience with the health plan Member complaints, problems getting services, and improvement in the health plan’s performance Health plan customer service 1 2
Ratings of Drug Plans (Part D) Drug plan customer service Member complaints, problems getting services, and improvement in the drug plan’s performance Member experience with the drug plan Member experience with the drug plan
US News:Highly Rated Medicare Advantage Plans Draw More Consumers Healthcare Payer News:Five Things You Need to Know About Changes to MA Star Ratings
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Effect of Star Ratings on Healthcare Consumers1 According to a study Medicare recipients who pick a Medicare Advantage plan are significantly more likely to choose a plan with a higher star rating than one with fewer stars – this is observed on both occasions; while people are choosing a Medicare plan for the first time and also when they are switching from another plan. The JAMA study analyzed 2011 enrollment information on more than 950,000 first-time enrollees and about 323,000 people who switched plans during that year. For every additional star a plan received, first-time enrollees were 10 percentage points more likely to choose that plan. For people who switched plans, each additional star increased by six percentage points the likelihood that they would choose it. Effect of Star Ratings on Healthcare Payers1
From 2012, Medicare has begun using the star ratings to peg payment to performance, by awarding billions of dollars in bonus money (approximately, $3 billion in bonuses, according to a Kaiser Family Foundation analysis) to insurers whose plans earned enough stars. New policy changes and the impact of Star Ratings2 Starting 2013, MA plans that have lower than three stars would be deprived of bonuses, resulting in $3.1 billion payments for the remaining 91 percent of contracts. One third of this would be received by plans with four stars and above two thirds would be shared among plans rated above three to three and a half and the plans which were not rated by CMS as they are either too new or had too few enrollees. Additionally, five-star plans can receive bonuses of up to five percent additional reimbursement and up to 10 percent in "double bonus" counties; Humana had one such achievement with their WI MA plan. New policies that allow MA beneficiaries to switch into a five-star plan at any time stand to gain more members and even more money. This opportunity however, can be availed only once during the calendar year. Only 11 plans out of 569 achieved that laudable goal in 2012. CMS has announced plans to add additional measures and redistribute the weighting of current measures in the coming years, giving greater weight to outcomes over process. MA plans with fewer than three stars are considered to be out of compliance. Starting 2013, their ratings will be posted on the CMS website and CMS will issue notices to enrollees in low-performing plans cautioning them to opportunities to switch to a higher quality plan. MA contracts terminated for plans that are continually low performing for three consecutive years.
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127 Medicare Advantage plans and 26 Medicare Advantage Prescription Drug and Prescription Drug plans have achieved four- or five-star ratings for the 2013 plan year.3 Challenges associated with CMS Star Ratings4 5 The U.S. Government Accountability Office and the congressional Medicare Payment Advisory Commission, or MedPAC, reported a concern; that Medicare is giving billions in bonuses to average plans. It takes only three stars for a plan to qualify for a taxpayer-funded bonus. – 91 percent of Medicare Advantage plans would have received bonuses in 2012. Bonuses being offered for health plans based on CMS Star ratings do not follow a transparent process due to lack of a comparison system in place and the change in the rating system’s methodology. Thereby raising questions – Does the star rating system really live up to its goal of measuring the quality of health plans? And, if it does, how should plans be rewarded for providing higher quality?
Star Rating system relies heavily on measures related to preventive screening of risk factors that may not be appropriate in managing care for the Special Needs Plans (SNPs) population – plans tailored to beneficiaries who have severe or disabling chronic conditions, are dually eligible for Medicare and Medicaid, and/or reside in institutions. Going forward…. The Star Ratings would have a continuous impact on delivery of quality care for seniors while holding stakeholders accountable for bending the cost curve. CMS has been moving to weighing outcomes and patient experience measures more than other measures. CMS included three SNP-specific measures in the 2013 Plan Ratings, however they have rejected the call to modify the Star Ratings system to better account for the beneficiary populations enrolled in SNPs. CMS has signaled that Star Ratings are likely here to stay and all signs point to the expanded use of these ratings for various aspects of the MA and PDP programs. As a result, in the coming years, CMS will: The Star Ratings would have a continuous impact on delivery of quality care for seniors while holding stakeholders accountable for bending the cost curve. CMS has been moving to weighing outcomes and patient experience measures more than other measures. CMS included three SNP-specific measures in the 2013 Plan Ratings, however they have rejected the call to modify the Star Ratings system to better account for the beneficiary populations enrolled in SNPs.
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Healthcare Payer News:Medicare Advantage, Drug Plans – Achieving, Maintaining a Five Star Rating US News: Ratings of Medicare Advantage Plans Take Fire 5 Bloomberg: Medicare Star Ratings–What Plan Sponsors Need to Know 4
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CMS has signaled that Star Ratings are likely to stay in the future and all signs point to the expanded use of these ratings for various aspects of the MA and PDP programs. As a result, in the coming years, CMS will:5 i. Continue to demand a strong level of quality and performance; ii. Expand the focus on improving beneficiary outcomes and experience; iii. Adopt new measures developed by consensus-based organizations to create a more robust measurement system; and iv. Consider alternative methods to evaluate a plan’s improvement Contracts Receiving the 2013 High Performing Icon Contract Type MA-PD MA-PD MA-PD MA-PD MA-PD MA-PD MA-PD MA-PD MA-PD MA-PD MA-PD MA MA MA MA PDP PDP PDP PDP
Contract Name KAISER FOUNDATION HP, INC. KAISER FOUNDATION HP OF CO KAISER FOUNDATION HP, INC. KAISER FNDN HP OF THE MID-ATLANTIC STS GROUP HEALTH PLAN, INC. GROUP HEALTH COOPERATIVE GUNDERSEN LUTHERAN HEALTH PLAN KAISER FOUNDATION HP OF OHIO HUMANA WISCONSINHEALTH ORGANIZATION INSURANCE CORP HEALTH NEW ENGLAND, INC. KAISER FOUNDATION HP OF THE N W MEDICAL ASSOCIATES HEALTH PLAN, INC. MEDICAL ASSOCIATES CLINIC HEALTH PLAN DEAN HEALTH PLAN, INC. KAISER FOUNDATION HP, INC. EXCELLUS HEALTH PLAN, INC HAWAII MEDICAL SERVICE ASSOCIATION (HMSA) WELLMARK IA & SD, & BCBS MN, MT, NE, ND,& WY CATAMARAN INSURANCE OF DELAWARE, INC.
5 Star Rating Last Year Yes Yes Yes No No Yes Yes No No Yes Yes Yes No Yes Yes Yes Yes Yes No
MA – Medicare Advantage Plans MA-PD – Medicare Advantage Plans offering Prescription Drug Coverage PDP – Stand-alone Prescription Drug Plans Source: CMS
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