The Findings on Duals’ Impact on Stars Are Out — But Now What?

By James Gutman - April 1, 2015

 

The findings certainly weren’t surprising, but the timing was at least interesting when Inovalon, Inc. on March 31 issued its long-awaited final report on the relationship between Medicare-Medicaid dual-eligible status and Medicare Advantage (MA) plans’ star ratings. The report thus came out six days before CMS must publish its final 2016 payment rates and Call Letter for MA insurers, including any further modifications in payments for MA insurers with large proportions of duals, especially MA Special Needs Plans (SNPs). But it seems likely that CMS will need more than six days to figure out exactly how to incorporate the study’s findings in its policies for star ratings and plan payments.

The study of more than 2.2 million MA beneficiaries in 81 separate MA contracts comprising 364 individual health plans seems extremely sound scientifically, including looking at multiple variables to determine the impact of duals status on performance as measured by stars. And the conclusions reached by the Inovalon researchers, especially that duals have worse outcomes than non-duals “given the same access and quality of care” because of the duals’ characteristics and not the plan’s quality of service, appear to have ample justification. The question, though, is what to do with this information.

“This is stuff we believed for years,” notes Rich Bringewatt, chair of the SNP Alliance trade group, which helped to bring about the new independent study. The findings are “pretty hard to refute,” he asserts, calling the approximately 90-page report including extensive appendices “a game changer.” Asked by AIS if the study will have an impact on the CMS final 2016 payment notice, Bringewatt responds, “I don’t know, but it should.”

One reason for the uncertainty is that CMS must deal with a situation in which duals aren’t just in SNPs but also in regular MA plans in varying proportions. So it is not a simple thing to say that duals should be rated in a different way for stars purposes, since any decision to do this would face even more complexities than does the already-risk-adjusted MA payment system now. Even Inovalon’s lead researcher in the study, Christie Teigland, Ph.D., acknowledges that it would be a very difficult and lengthy process for the agency to build all the needed statistical models itself. And the alternative she mentions, stratification to compare plans that serve a lot of duals to each other instead of to plans than don’t have many duals, would itself be complex.

So what should CMS do about the situation in both the short and long term? Many SNPs are going out of existence because their star ratings don’t qualify for the bonuses needed for financial viability, so what can be done about this right away? And since it is extremely difficult to prove the causal relationship between duals status and poor stars performance that CMS said would be its criterion for making major changes, what is likely to improve the situation even in the long run? As economist John Maynard Keynes said, “In the long run, we’re all dead.”

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