By Jane Anderson
The following is an article from AIS Health’s Health Plan Weekly. It was published as part of the AIS Report on Blue Cross and Blue Shield Plans. The AIS Report on Blue Cross and Blue Shield Plans — a monthly update for Health Plan Weekly subscribers — is published independently by AIS Health. Not affiliated with or sponsored, endorsed or approved by the Blue Cross and Blue Shield Association or any of the independent Blue Cross and Blue Shield companies.
Blue Cross and Blue Shield Medicare Advantage (MA) plans are struggling as a group to maintain and improve their CMS star quality ratings in a system that doesn’t favor their traditional strengths, analysts say. To compensate, some Blues insurers are partnering with provider organizations in an effort to drive up quality and member experience ratings.
Most beneficiaries continue to enroll in highly rated plans, but generally speaking, Blues plans did not perform quite as well as non-Blues plans or national insurers on their MA and Prescription Drug Plan (PDP) star ratings, says Melissa Smith, senior vice president, stars and strategy, for Gorman Health Group.
Blues plans are trying to change that, and “are constantly comparing themselves to best practices and competitors,” says Cary Badger, principal with HealthScape Advisors. “There are some that are taking a hard look at how to break that paradigm” of poorer performance, he tells AIS Health.
Overall, 2020 star quality ratings show that an overwhelming percentage of MA beneficiaries are enrolled in plans with 4 or more stars (HPW 10/17/19, p. 1). There also was a notable shift of membership into highly rated PDP plans, some of which made meaningful improvements on an individual basis even though PDP performance on average was stagnant.
More than half of MA-PD plans that will be offered in 2020 earned overall star ratings of 4 or higher, an increase over the 46% of MA-PD plans offered in 2019, according to CMS.
Still, out of 94 Blues-sponsored MA and MA-PD plans, an analysis by AIS Health shows that only two Blues-sponsored plans earned 5-star status for 2020: Coconut Grove, Fla.-based HealthSun Health Plans, Inc., owned by Anthem, Inc., and Florida Blue HMO.
Another 13 Blues-owned MA and MA-PD plans earned 4.5 stars: plans from Florida-based Freedom Health, Inc. and Optimum HealthCare, Inc., both purchased by Anthem in 2017; three Blue Cross Blue Shield of Minnesota plans; two Regence BlueCross BlueShield of Oregon plans; one plan sponsored by Regence BlueCross BlueShield of Utah; and plans sponsored by Blue Cross Blue Shield of Massachusetts, Blue Cross of Idaho, Excellus Health Plan, Inc., Highmark, Inc. and HealthNow New York, Inc.
Anthem Has Fewer High-Star Members
Twenty-seven Blues-sponsored MA and MA-PD plans earned 4 stars for 2020, including six from Anthem. Still, Anthem’s enrollment in contracts with 4 stars or more fell around 3% from 2019 and more significantly over the past two years, according to Evercore ISI equities analyst Michael Newshel. Two years ago, Anthem counted 89% of its MA enrollees in plans with ratings of 4 stars or more, but for next year the insurer will only have 58% of its enrollees in bonus-eligible plans, Newshel said in an Oct. 9 note.
A total of 33 Blues-sponsored MA and MA-PD plans earned 3.5 stars, including 13 sponsored by Anthem. Nine Blues-sponsored MA and MA-PD plans earned 3 stars, including four plans sponsored by Health Care Service Corp. On the PDP-only side, just Wellmark’s MedicareBlue Rx achieved a 4.5 rating, and two plans — sponsored by Blue Cross Blue Shield of Kansas and Highmark — achieved a 4-star rating.
Large Networks May Not Get High Stars
The star measures are “not a natural fit” for Blues plans, which traditionally have focused on having large provider networks, suggests Smith. CMS wants “private-sector flexibility and innovation, and those [descriptions] are alarming to most Blues plans,” she adds.
“Blues are trying to figure out how to succeed without losing their long-term differentiator. They’re struggling to keep pace where a lot of for-profit MA plans are chasing excellence. Old-school improvement doesn’t really get you to 4 stars and keep you at 4 stars,” Smith says.
Some Blues plans, however, are doing well on star ratings. For example, Blue Cross Blue Shield of Massachusetts’ PPO is rated 4.5 stars, its HMO plan has 4 stars, and its Blue Medicare Rx PDP received 5 stars for the fourth year in a row. And Blue Cross and Blue Shield of Alabama “had been at a 4, lost their 4 and then got it back” for 2020 for its MA-PD plan, “which shows you really can change health care quality, access to care and member experience,” observes Smith.
Still, she says, “there’s a good handful of Blues plans that are struggling. They know they’re struggling. They just can’t really seem to find their way.”
Getting to a 4-star rating “requires significant engagement with physicians and pharmacists,” Badger observes. “It’s a constant battle.”
Some insurers are considering teaming up with major medical centers or other provider groups as a way of improving quality and member experience, he says.
For example, Blue Cross and Blue Shield of North Carolina announced in April that it will partner with Duke University Health System to form a new insurance company, Experience Health, that will be targeted at seniors. Experience is offering its first MA product, an HMO touted as a “doctor-designed Medicare plan,” in North Carolina’s Research Triangle area for 2020.
“Star ratings is something they think they can break through — they are very focused on improving star ratings,” Badger says.
Plans Seek Provider Partnerships
In another partnership, Independence Blue Cross has partnered with Dedicated Senior Medical Centers in Philadelphia. Dedicated primary care physicians are considered preferred PCPs for Independence’s Keystone 65 HMO members, meaning copayments are $0. “That’s a partnership that is based on provider contracting strategy rather than a new joint venture,” Badger notes. “That’s one approach that’s rather novel.”
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