Drug Measures Hurt Star Ratings For MA Plans, Require Closer Ties

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care.

By James Gutman, Managing Editor

October 27, 2011 Volume 17 Issue 21

Perhaps somewhat lost in the focus on how much Medicare Advantage plans improved overall in the CMS star ratings unveiled Oct. 12 (MAN 10/13/11, p. 1) is how many problems they experienced on the prescription-drug portions of the ratings. CMS confirmed to MAN that problems reflected in plans’ scores on drug-related measures, which got more weight in 2012 than in previous years, constituted a major reason there were substantially more MA plans with ratings below three stars for 2012 than for 2011. But consultants commenting on the woes with the overall drug scores in general and the especially troublesome medication-adherence measure in particular did not envision any easy solutions.

The problems on the drug measures weren’t limited to MA plans. In fact, unlike for MA plans, overall ratings for stand-alone Prescription Drug Plans (PDPs) fell for 2012, with the average rating weighted for enrollment standing at 2.96, down from 3.49 in 2011, according to an analysis by consulting firm Avalere Health LLC. Moreover, Avalere said, of the 245 PDPs that bid low enough for 2012 to qualify for auto-assigned low-income subsidy (LIS) members, 67% had a decrease in their star ratings. Next year, the firm added, 52% of LIS-eligible plans are rated at only two stars, compared with just 3% of LIS-eligible plans this year. Put another way, of the 47 PDPs that had ratings of four or more stars in 2011, 11 were not eligible in 2012, and all of the remainder had a decrease in their 2012 ratings, Avalere noted.

The firm attributed this “precipitous decline” largely to changes in the star ratings for 2012. CMS overall, Avalere pointed out, put a greater emphasis for the 2012 ratings on clinical outcome measures such as medication adherence (MAN 8/18/11, p. 1). And PDPs, unlike MA plans, don’t participate in CMS’s large-scale demonstration program that awards quality bonus payments for plans that achieve ratings as low as three stars.

Part D Woes May Relate to Use of Vendors

Medicare Part D measures are a problem for MA plans themselves for a variety of reasons, said consultant Nathan Goldstein, executive vice president of Gorman Health Group, LLC, in an Oct. 20 AIS webinar on new star-rating requirements and shifting strategies for meeting them. Goldstein explained that many of the Part D measures are “controlled by delegated entities,” so they often are kept at an “arm’s length relationship” by MA plans. This makes it tougher to influence those vendors for purposes of improving star ratings, he suggested.

Jane Scott, vice president, clinical services at Gorman Health Group and the second speaker in the webinar, said one way of dealing with this is to develop outreach efforts aimed directly at the members. That’s harder to do in PDPs than in MA, Goldstein noted, because PDPs tend to be “diffuse” in their coverage areas.

“Part D really matters,” he maintained, citing, among other things, the greater disparity between high and low scorers among MA plans in the new star ratings than in the 2011 results. He pointed out that about 15% of MA contracts now are on CMS’s “watch lists” because of overall scores below three stars.

Asked when CMS might exercise its newly asserted power to remove MA plans that have had ratings below three stars three years in a row (MAN 10/13/11, p. 1), he said it could be as early as next year, but CMS should give another year after this to allow time for low-scoring sponsors’ corrective action plans to have an effect. He added that “CMS likes to keep bullets in the chamber.”

Not just in Part D but also overall, Goldstein said, MA plans no longer can afford, for star-rating purposes, to have “arm’s length” relationships. He said that includes the need to have closer relationships with providers, especially since HEDIS ratings, which include many provider-related aspects, still account for 35% of star-rating measures. Goldstein also pointed out that controlling blood pressure, clearly an area requiring active provider involvement, was one of the measures assigned the highest weight in the new star ratings.

Better ‘Attribution’ to Providers Can Help

A way of achieving closer coordination for MA plans with providers is better “attribution” of plan members to their primary care providers, says Kristian Marquez, senior director, clinical and quality outcomes for star-ratings data vendor MedAssurant, Inc. His firm, Marquez explains in an interview with MAN, uses “attribution logic” to determine the plan member’s primary care physician. He adds that such determinations require “capture” of data not usually obtained, such as the member’s results before joining the plan.

Additional uses of data that can help in boosting star ratings, Marquez says, include examining the member’s behavioral and other characteristics to clarify all the services that member needs. This could include overcoming such barriers to care as transportation, and that also requires working closely with providers, he says.

“All the low-hanging fruit is gone,” Marquez asserts. “Gone are the days” when a plan could just do campaigns directed at all members, he adds, and the focus now needs to be looking at individual members. In the past, explains Dan Rizzo, chief innovation officer at MedAssurant, not all members got plan attention, but this no longer is feasible, especially since the average MA member is assessed in about seven CMS star-rating measures.

Marquez says an aspect of star ratings that will become more important as CMS continues to boost its focus on outcomes is the frequency of delivering an outcome, such as a certain hemoglobin A1c level or an LDL (i.e., “bad”) cholesterol measure. This in turn, he explains, means ensuring members understand the tools the MA plans have in place, such as phone access to clinicians, to help members adhere to the correct care protocols.

To purchase a recording and accompanying materials from the Oct. 20 AIS star-ratings webinar, please call (800) 521-4323 or visit the MarketPlace at www.AISHealth.com.