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Overall Medicare Star Improvement Levels Off; Gains on Part D Side

Overall Medicare Star Improvement Levels Off; Gains On Part D Side

The Centers for Medicare and Medicaid Services (CMS) can continue to be happy about the progress it has made over time in improving quality outcomes in the Medicare Advantage (MA) and Part D (PDP) programs, but the 2017 Star announcement shows that many plans continue to struggle with quality. Year-over-year performance was generally flat (not a terrible thing by any means, given the overall progress the past few years), with standalone PDPs turning the corner a bit and MA-PD plans doing better in Part D measures as well.

Overall achievement

We like to benchmark the progress back to 2010, when Medicare Advantage quality was overhauled in the Affordable Care Act (ACA). In 2010, just 14% of Medicare Advantage Part D (MA-PD) plans had 4 Star or greater ratings and just 24% of all enrollees were in such plans. By 2016, 49% of MA-PD plans were 4 Star or better and 71% of enrollees were forecast to be in such plans. The 2017 Star announcement shows MA-PD plans’ 4 Star attainment staying steady at 49%, but projected enrollment in such plans dropping a bit to 68%. Further, the average MA-PD Star score dropped from 4.03 to 4.00.

Here is how the MA-PD plans faired:

  • Plan contracts for MA-PD dropped from 369 to 364.
  • The good news is the number of 5 Star plans increased from 12 to 14. However, as we noted last year, there is extreme volatility in 5 Star attainment. Four plans lost their 5 Star rating from 2016 and 6 new plans achieved it. Recent history shows it is the mark of a well-run, exemplary plan with committed staff to be able to achieve and then maintain 5 Star status.
  • Three additional MA only (no Part D benefit) plans achieved 5 Star status.
  • The number of 4.5 Star plans has increased from 65 to 67.
  • Given some of the increases above, the number of 4 Star plans dropped from 102 to 97.
  • Over 30 plans that earned 4 Stars or greater in 2016 dropped below 4 and will lose their 5% quality premium bonuses.
  • A number of the biggest and most prominent plan names that had previously scored high in Star have lost major ground (including plans that lost 5 Star this year and last and others that have dropped within the 4s and even gone below 4 over the past two years). At the same time, other big names saw great improvement in their results for 2017.
  • The number of 3.5 Star plans dropped from 112 to 107.
  • Those plans with 3 Stars and below increased from 78 to 79.
  • 2 MA-PDs were rated low performing three years in a row (2.5 Stars or below) and are potentially subject to termination at the end of the calendar year. There were 6 in 2016, the first year that the termination threat came into being. Some of the 2016 plans are still around, having received a reprieve. Congress may also pass a bill to stop these terminations (As the late great Speaker Tip O’Neill once said, “All politics is local!”).

The fact that 186 plans still languish below 4 Stars show the systemic challenges of about half of the MA-PD plan participants.

A bright spot is year-over-year standalone Part D (PDP) performance. The PDP Star achievement has been a particularly sore spot for CMS, with 2016 average PDP Star scores falling to 3.40, just 41% of PDP plans achieving at least 4 Star status, and just 32% of standalone Part D members enrolled in such plans. For 2017, marked improvement was seen, with 49% of PDPs getting to at least 4 Star and 41% of standalone PDP enrollees now in such plans. The overall average score increased to 3.55.

Part D scores for MA-PD plans tend to drag down overall MA-PD achievement. While MA-PDs did better on Part D scores in 2017 as well, surprisingly it did not translate into more 4 Star and above MA-PD plans (more on this later).

Here is how the PDP plans faired:

  • Plan contracts dropped from 59 to 55.
  • While there were just two 5 Star PDPs in 2016, there will now be 6.
  • Due to that change above, 4.5 Star plans will drop from 10 to 8.
  • 4 Star plans increased from 12 to 13, with 3.5 Star plans going from 12 to 16.
  • 3 Stars and below dropped from 23 to 12.

Achievement factors

As with last year, there is some significant correlation of high score achievement to certain factors for MA-PDs. CMS notes that MA-PD plans that are non-profit tend to receive higher ratings. About 70% of the non-profit MA-PD plans received 4 or more Stars compared to 39% for for-profit MA-PDs. While MA-PD plans that are owned by integrated delivery systems continue to perform well in the 5 Star category, more IPA and provider-network MA-PD plans are coming into the best-in-class group. And tenure in the program is a great barometer as well. Plans with a tenure of 5 or more years perform demonstrably better than those under 5 years, with 10 year or greater participation performing even better (a similar pattern could be seen for PDPs here). Like last year, the West Coast, Midwest, and Northeast MA-PD plans tend to have highest quality. Puerto Rico has made great strides, with its weighted enrollment in 2017 being 4 Star for MA-PDs.

Individual measure scores

The troubling aspect of the measure results for 2017 MA-PD Star is that there is significant volatility. There were many positive showings year-over-year in some measures but reduction (sometimes significant) in others. There are 47 MA-PD measures, 32 on the Part C side and 15 on the Part D side. 21 scores improved, 18 scores fell and 8 stayed steady. Breaking the measures out, for MA-PD plan’s Part C side scores: 15 improved, 10 fell, and 7 stayed the same. On the Part D side of MA-PD: 6 improved, 1 fell, and 8 stayed the same.

In the PDP world, there are 15 measures: 11 improved, 1 fell, and 3 stayed steady.

Major measure gainers for MA-PDs:

  • Breast Cancer Screening (hit 4.0)
  • Special Needs Plans Care Management (hit 3.0)
  • Pain Assessment
  • Controlling Blood Pressure (hit 4.0)
  • RA Management
  • Complaints About Health Plan for Part C and Part D
  • MPF Price Accuracy

Major measure losers for MA-PDs:

  • Improving or Maintaining Physical Health (dropped well below 3.0). Surprisingly the related mental health measure now well outperforms it.
  • Appeals Auto-Forward for Part D benefit. This measure is very much driven by many plans’ inability to timely process Redeterminations.
  • Appeals Upheld (pointing to the need to better zero in on the consistent use of medical necessity criteria)
  • High Risk Medication
  • Diabetes Medication Adherence
  • Cholesterol Medication Adherence

One other note: the hot button of the Medication Therapy Management Program’s Comprehensive Medication Review (MTM and CMR) – the measure inched up its bad performance in the MA-PD world from 2.3 to 2.4 (see more below).

Major measure gainers for PDPs:

  • Complaints About Health Plan
  • Members Choosing to Leave the Health Plan
  • Beneficiary Access and Performance Problems
  • High Risk Medications
  • Diabetes Medication Adherence
  • MTM Program Completion for CMR – this scored a miserable 2.3 in its freshman year in 2016 and is now up to 2.8. MTM has been a major focus of reform for CMS. This will help, but CMS believes far more work needs to be done. This is demonstrated by the new MTM pilot as part of the program audit.

Major measure losers for PDPs:

  • Call Center TTY and Foreign Language Interpreter

Interesting, too, is the fact there is a significant difference in how MA-PD plans’ Part D measure attainment and PDP measure attainment match up. MA-PD plans have higher Part D scores than the PDPs in 5 measures, but lower in 9 (with one being the same). MA-PDs score higher in 3 of the 5 clinical measures.

It is important to note a reduction in the average Star rating does not necessarily mean major changes in overall performance on certain measures. This is because the pre-determined thresholds used to set the Star levels were removed in 2016 and performance thresholds can now “inflate” from year to year based on overall attainment in measures. Star measures are essentially on a bell curve, so very high performing plans can move the percentage thresholds in each measure even as others stay roughly the same or even improve slightly. Plans falling behind on given measures need to be concerned. This was the whole purpose of the Star rating program – to force plans to practice continuous quality improvement.

Overall, analysis of the individual measures would point to the fact that while health plans can positively move scores from year-to-year, they also often seem to fail to be able to lock in the positive performance once better results are achieved and build on it. This causes the relatively flat performance and raises the question as to whether some plans have the rigorous infrastructure – in the quality, analytics, care management, and provider relations areas – to maintain higher and higher performance, especially as the highest performance keep driving performance thresholds up in the future. The loss of quality bonus for almost three dozen plans is a case in point.

As we have written often, the financial advantages of achieving 4 Star status are numerous. Plans with 3.5 Stars and higher are allowed to keep more premium (known as the “rebate”) that is passed through to members in terms of better benefits. Plans with 4 and greater Star achievement also get an additional 5% premium bonus to pass through to members in benefits. Plus, 5 Star plans get the supreme advantage of marketing to beneficiaries year-round, rather than just for 7 to 9 weeks for non-dually eligible Medicare enrollees. We have factored the rebate and quality bonus monies as giving plans an up to 11% benefit advantage in the marketplace.

So, while progress has stalled a bit in the Star program, plans must keep investing in Star infrastructure and pushing the limits to maintain competitiveness in the market.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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