CMS Mulls Income-Adjusting MA Stars

The Medicare Advantage star ratings program is already risk-adjusted for clinical factors such as comorbidities. Now federal officials are considering adjusting the quality rating program based on beneficiary income levels.

Under pressure from healthcare industry stakeholders and Congress, federal officials are considering making adjustments to the Medicare Advantage star rating program for quality and bonus payments to reflect the impact of socioeconomic status.

In early September, the Centers for Medicare & Medicaid Services requested comments on whether the MA star rating program should be risked-adjusted for SES. The focus of the federal agency is on dual-eligible beneficiaries: low-income individuals who are eligible for both Medicare and Medicaid services. "CMS seeks analyses and research that demonstrate that dual status causes lower MA … quality measure scores," agency officials said in the "request for information" document.

16 Medicare Advantage Plans Earn 5-Star Ratings

In August, the National Quality Forum, which vets quality measures for healthcare payers, issued a report calling for reforms that account for SES. The organization had previously resisted changes to quality measures to account for the impact of SES, but announced a change of course last month.

"NQF's Board approved a change in its current policy to allow for SES risk adjusting of some appropriate performance measures during a robust, two-year trial. The results of the trial will guide NQF on whether to make this policy change permanent. To be launched on January 1, 2015, the trial will be directed by the soon-to-be-formed NQF Disparities Standing Committee," NQF officials said in a statement.

The organization already accounts for clinical factors in quality measures and says "growing evidence shows that socioeconomic status and other demographic factors may also influence patient outcomes."

In an interview last week, an NQF official said any adjustment to the set of measures in the MA star rating program should be carefully calibrated. "The outcome measures are more likely to be appropriate for adjustment," said Ann Greiner, the organization's VP of public affairs. "This is not a blanket recommendation to adjust all stars measures."

MA Plans Under Star Rating Pressure
New York-based Healthfirst Inc. has firsthand knowledge of the challenge of achieving MA star rating success while serving dual-eligible beneficiaries.

"It becomes a very vicious cycle," says Joyce Chan, assistant VP of clinical performance at Healthfirst.

MA health plans that have a high percentage of dual-eligible members face a "double whammy," she says, because it is difficult to cross the 4-star threshold that garners the highest bonus payments. "You don't get the quality bonus money… then services get cut. The members are the ones that suffer."

Healthfirst has posted a 4-star MA quality rating for the 2015 plan year, but it was a struggle for several reasons:

• Cultural diversity: 53% of Healthfirst's MA beneficiaries speak English as a second language
• Education level: 70% of beneficiaries have less than a high school education
• Poverty and crime rates: The majority of beneficiaries reside in neighborhoods with nearly one-third of residents living in poverty
• Physician gap: 66% of beneficiaries live neighborhoods federally designated as health professional shortage areas

The statistics are linked to concrete MA star rating challenges such as dietary restrictions for diabetics conflicting with cultural norms. "Telling a Chinese plan member not to eat rice is really hard," Chan says.

Healthfirst favors a two-stage approach to factoring SES into the MA star ratings. "Risk-adjusting is the appropriate long-term solution, but it will take time to establish the adjustment model," she says.

In the meantime, Healthfirst wants CMS to adopt other options such as the federal agency's value-based purchasing model for hospitals. Under the purchasing model, hospitals are rewarded for year-to-year improvement or achievement of set performance standards. "It's a great interim solution, but it's hard to sustain improvement year after year after year," Chan says.

CMS Feels Star Rating Heat
Members of Congress are pressuring CMS to adjust the MA star rating program to reflect the challenges of serving dual-eligible beneficiaries.

Four bipartisan House members—Rep. Diane Black, (R-TN), Rep. Earl Blumenauer, (D-OR), Rep. Cathy McMorris Rogers, (R-WA), and Rep. Mike Thompson, (D-CA)—wrote a letter to CMS Administrator Marilyn Tavenner on Nov. 14, urging her to act:

"The MA program plays an important role in helping 16 million beneficiaries access high-quality health care, including delivering coordinated care to dually-eligible beneficiaries and other low-income seniors who often experience higher rates of chronic illness, disability and mental illness."

"It is well established that social determinants of health, including socioeconomic status, are important drivers of health outcomes. Dually-eligible individuals are amongst Medicare and Medicaid's most vulnerable beneficiaries and those most in need of the additional benefits and services, care management, and coordination across providers that MA offers. We are, therefore, concerned that the current MA quality and resultant payment system does not capture the social determinants of health that these beneficiaries may face."

Health plans are definitely concerned.

On Nov. 3, Jeff Myers, president and CEO of Medicaid Health Plans of America, expressed his MA star rating misgivings in a letter to CMS Deputy Administrator Sean Cavanaugh.

"Unfortunately, current Star quality measures do not adequately take into account the significant issues that low socioeconomic status has upon the achievement of favorable and preferred health outcomes as well as adverse impact upon plan performance," Myers wrote.

He cited a study conducted from 2011 to 2014 by America's Health Insurance Plans, showing that "plans with greater than 50% enrollment of low-income beneficiaries achieve lower Star ratings than plans that enroll less than 50% of low-income beneficiaries. It also finds that this disparity is growing overtime. Health plans that serve a higher percentage of low-income beneficiaries achieve Star ratings that were found to be 0.5 stars less than plans that serve fewer low-income beneficiaries."

Medicare Watchdog on Alert
Officials at the New York-based Medicare Rights Center are resisting the push to adjust the MA star rating program for SES. "To our knowledge, there is no data proving a causal link between disadvantaged populations and lower plan quality scores," says Krystal Scott, the advocacy group's New York State policy director.

Scott says CMS needs to tread carefully as the agency weighs adjusting the MA star ratings for SES. "Dually eligible beneficiaries may well have health needs that are different from healthier, higher-income populations. Yet, this does not necessarily mean they are more difficult to serve—only that their service needs may be different from other populations. Further, there is data suggesting that dually eligible beneficiaries are more likely to receive poor quality care, but the data do not show that this substandard care is caused by the actions or circumstances of these patients."

CMS has options beyond adjusting the MA star ratings, Scott says.

"We would like to see CMS ensure that appropriate tools are used to encourage high-quality plans to enter and remain in the market to serve dually eligible beneficiaries. Another option would be to compare health plans with similar proportions of low-income patients to each other, rather than comparing them to all Medicare Advantage plans."

CMS is reviewing public comments and could announce a policy proposal as early as February.