By James
Gutman, Managing Editor
December 4,
2014 Volume 20 Issue 23
There were few surprises and only one
brand-new measure — but some important potential changes — outlined in CMS’s
Nov. 21 memo on proposed “enhancements” to its Medicare plan star quality
ratings for 2016 and beyond. This year’s 22-page edition of what has become an
annual document makes clear, for instance, that CMS intends finally to end use
of predetermined four-star “thresholds” effective with the 2016 ratings.
However, the agency is asking for
industry input — by the Dec. 17 overall comments deadline — on how that should
be done, including via a phase-out or with a periodic adjustment versus a
one-time change.
Perhaps equally important, the memo
also says that “CMS is exploring the development of an integrated Star Rating
system for Medicare-Medicaid Plans” participating in the CMS-backed capitated
duals demos that began this year (see story, p. 4). Such a rating system
“acknowledges the additional needs of Medicare-Medicaid enrollees” and would
measure performance of the duals plans in integrating Medicare and Medicaid
benefits, states the memo. Its language there appears to acknowledge industry
concerns about the adverse impact of the stars system on plans that serve
disadvantaged populations (MAN 9/11/14, p. 1), but could mean CMS is not
considering any other short-term steps to aid Medicare Advantage insurers
serving the disadvantaged.
CMS May End Four-Star Thresholds
The memo was sent to insurers via CMS’s
Health Plan Management System by Amy Larrick, acting director of the Medicare
Drug Benefit and C & D Data Group. It also indicates the agency intends to
go ahead for 2016 with a delayed measure assessing the completion rate for
Comprehensive Medication Reviews (CMRs) for beneficiaries eligible to
participate in medication therapy management (MTM) programs (MAN 12/5/13, p.
4).
Several of the contemplated revisions
outlined in the memo result from methodology or other changes made by
accreditation organization NCQA, especially in its HEDIS measures. Others,
though, represent areas CMS on its own has wanted to alter for a while.
Perhaps the most significant of those
revisions is the abolition of predetermined four-star rating thresholds used
for 2015 in 67% of MA measures and 39% of Part D drug measures. CMS said in the
memo, as it has in the past, that these thresholds violate its “principle of
assigning stars that maximize the difference between star categories” and
represent a problem “when there is general improvement in measure performance
over time.” The agency added, though, that while its analysis shows plan
sponsors improve more in measures without preset thresholds (51% of contracts
improved significantly in nine MA measures without thresholds versus 28% in 20
measures with them for 2015), it recognizes some sponsors feel they need the
published targets to set “performance expectations.”
So while “we propose removing the
pre-determined measure thresholds for the 2016 Star Ratings,” the memo said,
CMS is asking for input on whether to do this as a phase-out rather than all at
once. The agency cited as a possible method the elimination of the thresholds
on “process” stars measures for 2016 and on the remaining measures for 2017.
And CMS said it could address “industry’s request for stability via
pre-announced benchmarks” by adding an annual improvement percentage increase,
to be adjusted not more than once every three years, that initially reflects
improvement trends the agency has seen from 2014 to 2015 in the star ratings.
The phase-out option is “interesting”
and “not what we would have expected” in light of CMS having advocated the
elimination of the thresholds for years, says Carmen Alexander, manager,
strategy and operations in Deloitte’s government health plans consulting
practice. She attributes the possible change to feedback from plans, and Michael
Lutz, director, health reform for consulting firm Avalere Health LLC, tells MAN
the alternatives show CMS is looking for a “less disruptive” way of
accomplishing its goal.
The two options CMS outlined on this
are “very feasible,” says Christie Teigland, Ph.D., director, statistical
research for health data analytics firm Inovalon, Inc. Teigland adds, however,
that adjusting for improvement every three years is “too infrequent” and that,
as a statistician who agrees with the agency’s arguments against the four-star
thresholds, she’d prefer it if CMS would just get rid of them in one step.
Nevertheless, she tells MAN, the
thresholds do serve a purpose, especially since CMS’s methodology on some of
the star ratings is still “a little of a black box” and since without the
thresholds “it’s hard for plans to know how to get an ‘A.’”
Duals MA Plans May Not Get Relief in 2016
In noting its exploration of a separate
star-rating system for plans in the duals demo and saying it will have more
details on that in the first quarter of 2015, CMS will “roll the ball forward”
in recognizing the particular issues surrounding star ratings in plans for
duals, according to Teigland. But she terms it “a little disappointing” that
CMS didn’t say more on this issue, which is the subject of a large new
multi-payer study being conducted by Inovalon (MAN 11/6/14, p. 1). Asked
if the agency’s statements in the memo could mean CMS is not intending to do
anything additional on the duals star rating issue for 2016, Teigland replies,
“That’s how I’m reading…between the lines.”
Alexander agrees that the likelihood of
CMS doing more to help Medicare plans serving the disadvantaged for 2016
outside of the duals demo is “a bit of a stretch.” She cites the amount of data
analysis and plan comments the agency must wade through in the aftermath of its
Sept. 8 request for evidence proving disadvantaged status causes poorer star
ratings.
The only totally new measure that CMS
says in the memo it intends to add for 2016 is its previously proposed MTM
completion rate for CMRs. This measure has been controversial, especially
regarding its possible application to long-term care beneficiaries, and the
memo says nothing about excluding populations other than those in hospice at
any point in the reporting period.
Lutz, though, does not expect to see
further delays in instituting the measure, especially since CMS detailed in the
memo that it not only would start with the standard new-measure weight of 1 but
also would keep that lowest possible weight as a process measure in future
years. Alexander agrees, noting the CMR completion rate for MTM eligibles now
is only 15%, that rates vary from 0% to 90% among plans, and that the agency
considers CMRs important. There will be “a lot of variance” in plan scores when
this measure is added, she asserts.
The CMS memo identifies three former
star measures, which had been withdrawn from active stars scoring because of
methodological or data-quality concerns, that the agency intends to return to
active status for 2016. They are breast cancer screening, call-center access
and “beneficiary access and performance problems.”
Alexander says none of the
reinstitutions are surprises, and CMS is changing the breast cancer screening
criteria in ways that should enable plans to do better on them. Moreover,
call-center access is a measure on which MA and Part D plans have done well in
the past, and the decision to remove audit results from the criteria in the
beneficiary access measure should reduce any “unfairness” in scoring plans that
have been audited versus plans that haven’t, she tells MAN.
On the flip side, the memo says CMS
intends to remove temporarily — for both 2016 and 2017 — the MA measure on
improving bladder control for multiple reasons, including that NCQA is adding
an “outcome indicator” involving revised survey questions first to be asked in
2015.
Bladder control is a “very-low-performing
measure,” notes Alexander, so its temporary removal is “a good thing” for
plans. When the measure comes back, she forecasts, it will be “reconfigured” to
focus on what plans need to do to improve a member’s quality of life.
CMS in the memo also is proposing to
help make more plans eligible for star-rating scoring by reducing the minimum
size of plans scored to 500 members from the previous 1,000, based on its
conclusion that there are “sufficient data to reliably measure and report on
contracts” with the smaller number of enrollees.
This could help good smaller plans that
now are limited to a 3.5% bonus if they are too new or small to get CMS stars
scores, says Alexander. Teigland, though, cautions that “500 is a pretty small
number” considering that many enrollees don’t qualify for inclusion in CMS’s
member count for stars purposes. This raises the question of whether the
remaining number of members after the required exclusions will be enough to
yield suitable data, she explains.
In a later section of the memo, CMS
lists and explains potential changes to existing star measures and possible new
measures it is considering for 2017 and beyond. In the latter category are:
- Care coordination measures based on the encounter data MA plans now are required to submit;
- Asthma medication measures;
- Measures to assess depression screening, follow-up and response to treatment;
- Hospitalizations for potentially preventable complications;
- Statin therapy measures; and
- Opioid overutilization measures.View the CMS stars enhancement memo by visiting the Dec. 4 From the Editor entry at your subscriber- only Web page: www.aishealth.com/newsletters/ medicareadvantagenews.
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