Featured Health Business Daily Story, Dec. 13, 2013

D-SNP Groups Say New Studies Show CMS Stars System Discriminates Against Them (with Table: Distribution of MA Contracts’ Star Ratings by SNP Member Share)

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
December 5, 2013Volume 19Issue 23

Organizations representing or working with health plans that have or may get Medicare-Medicaid dual-eligible members are launching a major effort aimed at remedying the relatively low quality payments those plans receive based on their CMS star ratings. The organizations contend that the nature of the duals population and its health status puts those plans at an unfair competitive disadvantage in getting much-needed bonuses from CMS that are based on star scores and thus pose a big problem as duals integration initiatives become widespread. But finding a solution in keeping with CMS’s oft-stated position that there shouldn’t be different standards for good medical care in different parts of the nation could be difficult.

The new efforts at focusing attention on the duals pay issue include an about-to-be-issued study conducted by Milliman for the SNP Alliance on the impact of changes in the Hierarchical Condition Category (HCC) payment methodology for Medicare Advantage plans on target populations served by MA Special Needs Plans (SNPs). The report, among other things, looks at payment disparities for plans serving duals versus non-duals.

And on Oct. 30, stars analytics specialist Inovalon, Inc. released a research study that found “a significant association exists between dual eligible status and lower performance on specific Part C [i.e., MA] and D measure star ratings.” Among other things, the study, which Inovalon CEO Keith Dunleavy, M.D., tells MAN is “the largest and most comprehensive analysis of the duals/quality/star issue,” found a “significant and growing performance gap” between duals and non-duals in MA plans. It examined ratings for well over 1 million MA beneficiaries (more than 260,000 of them duals) on 10 stars measures for MA plan members in both 2011 and 2012.

The study didn’t look into why the performance gap is widening, according to Dan Rizzo, chief innovation officer at Inovalon. But data have shown that the duals population uses health care as much or more than do non-duals, so it’s more an issue of beneficiary “compliance” than of “access,” Rizzo tells MAN. “There is a cohort of patients for whom brute force does not work,” he asserts, referring to efforts just to get these beneficiaries to see providers.

Adding impetus to the overall campaign are the 2014 star ratings that CMS released in October (MAN 10/24/13, p. 1). They continued the trend of SNPs for duals (D-SNPs) posting relatively low star performance, although there were seven plans in which 85% or more of the enrollees were duals that got overall ratings of four or more stars. The seven are Commonwealth Care Alliance, HealthPartners, Medica Health Plans, Partnership Healthplan of California, Prime West Central County-based Purchasing Initiative, UCare Minnesota and UPMC for You.

Since the 2014 ratings will be used for bonus payments to plans in 2015, only those plans earning four or more stars will be eligible for CMS bonuses — unlike for the 2013 ratings that enabled plans with three or more stars to receive such aid.

CMS shows little or no indication of changing its basic stars stance on duals. “Medicare beneficiaries who are also eligible for Medicaid and enrolled in a Special Needs Plan must have access to care that is coordinated and meets their health care needs,” a spokesperson tells MAN. Agency officials are known to believe that D-SNPs are capable of getting four or more stars and that all MA plans should be scored on their overall achievement relative to national or other appropriate benchmarks and not have a lower bar to reach. Nevertheless, CMS still is exploring the feasibility of controlling for the concentration of providers in a geographic area, so that might offer some future relief for rural D-SNPs.

The agency’s hands are somewhat tied on a significant number of its current star measures because it uses so-called consensus-driven standards for them. These include ones derived through the NCQA’s consensus-driven process, which decides whether case-mix adjustment is needed. Generally, NCQA and the National Quality Forum have opted for case-mix adjustment on actual outcome measures — such as all-cause hospital readmissions — but not on process measures.

Gap on Stars Scores Is Widening, Inovalon Says

While there had been a gap previously between how duals and non-duals fared on specific MA and Part D individual stars measures, “the gap has widened in reported star ratings for 2012 and 2013 compared to previous findings,” Inovalon said in its study abstract.

Specifically, according to the company, “examination of 80 CMS MA contracts indicated that dual-eligible members performed worse on nine of the ten star measures that were investigated.” Moreover, even after the study controlled for “demographics, socioeconomic characteristics and severity of illness,” the duals “consistently underperform on eight of the ten measures investigated.”

This led Inovalon to conclude that “the five-star rating system in its current state may penalize MA plans serving a high proportion of dual eligible beneficiaries. Lower star ratings result in lower incentive payments and may lead to reduced services to dual eligibles.”

Inovalon also analyzed all 520 MA contracts on 10 selected key measures using their 2013 star ratings and found duals performed worse than nonduals on nine of them. The only measure on which duals scored better was diabetes treatment, as measured by the percentage of diabetic enrollees getting at least one prescription specific to treatment of the disease, the company noted. But Inovalon added that rates of compliance on this measure are high in the overall MA population since it requires just one prescription during the membership period and does not need a diagnosis of diabetes or hypertension.

On the other measures tracked, according to the company, duals showed significantly worse (1) treatment rates for rheumatoid arthritis; (2) preventive screening rates for breast cancer and glaucoma; (3) outcomes following hospital stays, as measured by readmissions to hospitals within 30 days of a prior discharge, even after adjusting for other factors related to readmission risk; and (4) results on Part D measures, including use of high-risk medications and adherence to cholesterol and antihypertensive medications.

Comparing MA plans with high and low percentages of SNP members on star ratings yields a striking result, based on the company’s analysis. “Contracts with a high percentage of SNP members performed worse 86% of the time (i.e., lower rates observed on 18 of the 21 measures evaluated),” Inovalon said in the report. “For example, MA plans with [a high percentage of] SNP members performed worse on all three medication adherence measures in 2013 as compared to plans with low numbers of SNP enrollees [see table, below]. The average star rating was lower by 0.5 to 1.0 star.”

The findings in the study in some ways parallel recommendations for modification of the star-rating system in an October 2012 report by Shawn Bishop, an independent consultant and former top health staffer for Senate Finance Committee Chairman Max Baucus (D-Mont.). Bishop’s recommendations included:

  • “Case-mix adjust more of the HEDIS and HOS [i.e., Health Outcomes Survey] measures” used in star ratings to “account for some of the variation observed” among plans, especially those ones that serve disadvantaged populations;

  • “Construct standards (cut points) based on performance in the same geography, not on a national basis”;

  • Make a plan’s improvement in the star ratings from year to year a greater part of the rating system; and

  • “Select measures for SNPs that are more relevant for the populations they serve,” including more measures designed for duals.

CMS in the past has been resistant to such suggestions, contending that all beneficiaries deserve the same quality. “Fundamentally,” says Inovalon’s Rizzo, “we agree” that a segment of the MA population “shouldn’t be allowed to be noncompliant” with the standard of care, but he contends that there are better ways to measure what is occurring among duals. He notes that CMS already recognizes such differences in having a SNP-specific stars measure on care for older adults and by having different expectations for hospital readmissions in different beneficiary populations.

Even after adjusting for beneficiary income, severity of illness, ethnicity and locations in the Inovalon study, adds Christie Teigland, Ph.D., the firm’s director of statistical research, star-rating measures were worse for duals.

What to do about the disparities in the stars system is a “tough question” and one that the Inovalon study did not try to answer, Rizzo acknowledges. But he says some kind of adjustment for “cognitive impairment,” to reflect that duals may have considerable difficulties, for instance, in remembering care or even understanding questions used in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey utilized in several stars measures, could be warranted.

Distribution of Medicare Advantage Contracts’ Star Ratings by Percentage of Special Needs Plan (SNP) Members*

Contract Group

Number of MA Contracts

Bottom 10%

Top 10%

Below Median

Low % of SNP members





Medium % of SNP members





High % of SNP members





* For 2013 star ratings based on 2011 data for 21 selected measures.

SOURCE: Inovalon, Inc. research brief, “The Impact of Dual Eligible Populations on CMS Five-Star Quality Measures and Member Outcomes in Medicare Advantage Health Plans,” Oct. 30, 2013.

© 2013 by Atlantic Information Services, Inc. All Rights Reserved.

On Jan. 29, get the latest intelligence on Medicare Advantage star ratings, including likely changes to 2015 measures and what plans should do about them. New Strategies to Maximize Your Medicare Star Ratings is a unique virtual conference that will provide — from the convenience of your own office or conference room — practical training on how to adjust your stars strategies to succeed under current measures while building an organization that anticipates new CMS demands on the horizon. Click here for program and speaker information, and to register today!

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