Quality Ratings for Medicare Advantage Plans

Orlando—The Centers for Medicare & Medicaid Services (CMS) introduced its 5 Star Ratings system to hold Medicare Advantage plans responsible for delivering improved care and for providing information to patients to make better decisions. Plans are ranked based on >50 measures across 5 domains, and patients are able to compare them.

There are some unresolved issues that need to be addressed, according to Benjamin Littenberg, MD, medical director at Patient Engagement Systems^®, a software company focused on coordinating and managing care for chronic conditions in the primary care setting. He spoke at the Spring Managed Care Forum in a session titled Using Patient Engagement and Clinical Decision Support to Improve CMS 5 Star Ratings: A Case Study.

“It is a federal program, so it is not that simple,” Dr. Littenberg said.

The 5 Star program is a pay-for-performance system in which plans receive payments based on 5 domains: (1) screenings, tests, and vaccines; (2) managing chronic conditions; (3) plan responsiveness and care; (4) member complaints; and (5) customer service.

The measures are culled from numerous sources, including CMS, the Healthcare Effectiveness Data and Information Set, the Consumer Assessment of Healthcare Providers and Systems, the Health Outcomes Survey, and the Independent Review Entity. They have various weights, depending on how important they are to improving quality. For instance, medication review for older patients has a weight of 1.0, customer service has a weight of 1.5, and improvements or maintenance of physical and mental health have a weight of 3.0 (the highest weight).

Plans are rated on a scale ranging from 1 (poor) to 5 (excellent). Bonus payments are received for a 4 (above average) or 5 rating. Plans that receive a 1-, 2-, or 3-star rating are not penalized, but Dr. Littenberg said that could change in the future. The lower-rated plans may receive reduced Medicare payments from the government, and CMS may even decide not to renew their contracts, which means the plans would not be eligible to treat Medicare patients or be eligible for reimbursement.

Dr. Littenberg said CMS publishes the Star Ratings on an annual basis and makes them available to the public. However, most people do not consult the ratings before enrolling in a plan.

There are other issues, as well, according to Dr. Littenberg. Many physicians still harbor an aversion to using technology such as electronic health records, making it difficult to monitor patient data. In addition, because patients often see multiple physicians for different conditions, there are also challenges in interpreting test results. If >1 physician examines a test result, they often disagree on the conclusion, particularly for complex, chronic conditions such as diabetes.

Another major problem, according to Dr. Littenberg, is that most providers treat patients on an individual basis rather than utilizing population health management to improve management of all of their patients. Practices are also sometimes lax in tracking patients and providing follow-up reminders, causing them to miss appointments and receive inadequate care.

Patient Engagement Systems has developed a registry-based approach to software that integrates patient data from multiple laboratories and gives providers valuable information regarding their patients’ health, according to Dr. Littenberg, who has been the company’s chief medical officer since 1999. He said the company adheres to national guidelines and updates the data after each laboratory test, sends reminders to physicians and patients about upcoming visits, and provides quarterly population reports to practices. Dr. Littenberg added that the program has contributed to improved clinical processes, higher patient satisfaction, better disease control, and lower costs of care.