Four Star Plans May Get Higher Bonus; Low Plans Face New Woes

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
March 1, 2012 Volume 18 Issue 4

Four-star rated Medicare Advantage plans stand to get an extra percentage point of quality bonus in 2014, the last year of CMS’s bonus demonstration program, under a provision of the agency’s “45-day notice” and preliminary call letter released Feb. 17 (see story, p. 1). But CMS also in the document proposed a policy in which Medicare beneficiaries starting in 2013 no longer will be able to enroll directly via the agency’s Medicare Plan Finder online tool in MA and Part D plans that bear a low-performing plan icon because they had ratings of less than three stars. And CMS plans to issue notices to members in plans that have been low rated for three consecutive years offering the beneficiaries a special enrollment period (SEP) to move to a higher-rated plan.

In addition, CMS adopted most but not all of the 2013 star-rating changes it outlined as under consideration in an unprecedented memo to plans Dec. 20, 2011 (MAN 1/5/12, p. 1). Among the additions proposed in the call letter are a measure to reflect year-to-year quality improvement by an MA or Part D plan, and a measure of care coordination drawn from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey administered in 2012 for MA plans only.

Abundance of Detail About Stars Is Unusual

The abundance of references to star ratings in the call letter is “not a huge surprise,” says consultant Stephen Wood, senior vice president of OptumInsight. What is a “little surprising,” though, Wood tells MAN, is the amount of detail about stars in the notice. He points out that CMS addresses in the notice industry concerns about the ratings and says it appears to be “trying to put a little more rigor” around the processes surrounding the star-rating measures.

The change in the bonus for four- and 4.5-star ratings in the CMS demonstration program is for 2014 only. It means those plans will get a 5% bonus that year compared with 4% in the former schedule.

“The goal is clearly to get plans to improve,” CMS officials said regarding the proposed changes for both high- and low-rated plans. But there is no indication in the call letter that the demonstration program with bonuses will be extended beyond 2014, as MA plans have hoped, Wood notes.

While CMS proposes to go ahead with its proposal to assign all new plan ratings a weight of 1 (the lowest possible) during the first year, it retreated from a contemplated change moving the classification of two “high risk medication” drug safety measures. The agency had considered covering prescribing patterns for patients with diabetes and hypertension as just “process” measures carrying the lowest rating, but opted instead in the call letter to keep them as “intermediate outcome” measures with the top weighting of 3.

“Recategorizing these two important patient safety measures as process measures would actually contradict CMS’ continuing efforts to recognize quality initiatives by prescription plans,” the agency explained in the call letter.

CMS is going ahead with changes it outlined last December to “retire” measures to the display page (i.e., still scored but not used in calculations of plans’ star ratings) that are related to access to primary care doctor visits and administration of pneumonia vaccine.

Also proposed for being added to the display page is a host of other measures, including a couple of major ones CMS indicated it is considering for actual rating measures for 2014.

One of them, according to CMS, is “measures from the Hospital Inpatient Quality Reporting program.” Specifically, the agency said, “we are exploring whether the individual-level hospital data can be associated with individual MA contracts.” CMS notes that the goals would be to create “an MA contract-level measure of the hospital care that enrollees in each contract receive.”

The other is a medication therapy management program measure for Part D plans based on the percentage of MTM-eligible beneficiaries who received a comprehensive medication review.

Potential 2014 Measures Include CCIP, QIP

Other measures under consideration for addition in 2014, according to CMS, include use of highly rated hospitals by MA plan members, evaluation of an MA contract’s Chronic Care Improvement Program (CCIP) and Quality Improvement Project (QIP), grievance rate per thousand enrollees in both MA and Part D, “appropriate implementation of Part D transition processes by plans to ensure continuity of care for beneficiaries,” “serious reportable adverse events” (including Hospital Acquired Conditions) and an MA Special Needs Plans care management measure.

None of those seems surprising to observers. Equally unsurprising is CMS’s note in the call letter that it intends to initiate action to terminate the contracts of MA or Part D plans that have had three consecutive years of summary ratings of less than three stars and that the agency has confirmed, via looking at the data underlying the ratings, are in “substantial noncompliance” with MA or Part D requirements.

View the call letter at www.cms.hhs.gov/MedicareAdvtgSpecRateStats.