Special Needs Plans (SNPs) have long argued that the current Star program discriminates against standalone SNP plans, plans with a major focus on SNP products, or a high percentage of duals. A new study just released by the Centers for Medicare & Medicaid Services (CMS) seems to give some credence to this argument and data to back it up. This may mean that SNPs will someday see the reforms they want in order to better compete in the rigorous Star program.
CMS has been reticent to tackle this frustrating issue for SNPs in the past. It had systemic issues to address. First, CMS was busy building a model Star program to incentivize performance. Indeed, it has done so and the results are impressive, with the number of high-performing plans and the number of enrollees in such plans growing dramatically. In past blogs, we have stated that CMS is not resting on its laurels, but building even more challenging quality performance policies for plans to further drive outcomes in the coming years.
Secondly, the SNP program in general was in shambles just a few short years ago. Both Congress and CMS policymakers distrusted the majority of SNPs; they perceived SNPs as year-round marketing tools and questioned their commitment to quality and achievement. SNPs were put on a number of life-support extensions as CMS crafted a cogent policy for their futures. A strong policy was developed over time and today SNPs, through certification through the National Committee for Quality Assurance (NCQA) and aggressive emerging audit standards for the Model of Care, seem to have a major commitment from CMS. Indeed, the Medicare-Medicaid Plan dual demonstration programs in states, the so-called sisters of the Fully Integrated Dual Eligible (FIDE) SNPs in Medicare Advantage, are a keen focus of CMS today. Policymakers see these plans as ways to rein in the huge costs and poor quality of service in both the acute and long-term care sides of Medicare and Medicaid.
With the good work above behind them, CMS officials now seem to be willing to address the inequities SNPs see when it comes to Star. Research conducted by the RAND Corporation and subsequently published on CMS’ website, had the goal to provide scientific evidence as to whether MA or Part D sponsors that enroll a disproportionate number of Dual Eligible (DE) and/or Part D Low Income Subsidy (LIS) beneficiaries are disadvantaged by the Star ratings program. In general, LIS and DE beneficiaries are under 150% of the federal poverty income level and many of them are entitled to both Medicare (due to age or disability) and Medicaid (due to low income).
About 26.2% of Medicare Advantage beneficiaries are Low Income Subsidy or Dual Eligible (LIS/DE), Disabled, or both LIS/DE and Disabled. Distribution of MA Contracts tends to either have a very high percentage (greater than 95%) of LIS/DE beneficiaries or a very low percentage (less than 20%) of LIS/DE beneficiaries. By nature of their product and benefit design (dual eligible, disease state or institutional focus), SNPs tend to see a disproportionate percentage of duals or LIS enrollees.
The research focused on 16 clinical measures during the analysis. The measures selected were beneficiary-focused issues, rather than plan-focused issues. The research did not include measures that were projected to be retired or revised, applicable to only Special Needs Plans (SNP), or already adjusted for socioeconomic status. The research included examinations of an LIS/DE effect and/or Disability effect on performance and the likelihood of these enrollees receiving the recommended care. The research also investigated the variations within contracts and differences between subgroups for a particular contract. The methodology used Odds Ratio to report on the relationship between performance and LIS/DE and/or Disability status.
The research did find evidence of differences in performance between LIS/DE and non-LIS/DE, and Disabled and non-Disabled beneficiaries within a contract. LIS/DE and/or Disability beneficiaries were less likely to receive the recommended care for about 12 of the 16 measures reviewed. At the same time, there were a few measures which showed that these types of beneficiaries would more likely receive a recommended outcome than some measures (this very well could be due to the strong focus by SNPs in these areas.). Overall, the findings did demonstrate that there exists an LIS/Dual/Disability effect for a subset of the Star Rating measures. Therefore, those plans with higher number of LIS/DE and/or Disability beneficiaries will be at a disadvantage in the Star Rating and as they seek to achieve 4 and 5 Star status. This becomes more and more concerning as CMS continues to refine the Star program and the 4 Star thresholds keep moving higher and higher through vigorous performance improvement at the plan level.
With the outcome of this research, should CMS apply an adjustment factor to the overall Stars rating score to represent the unique challenges faced by plans with a high population of LIS/DE and/or Disability members? Or, with CMS already establishing a slightly different MMP type quality incentive program in dual demo contracts in various states, will a separate MA-SNP and MMP Star program emerge on the horizon over time?