Star Ratings have driven the market in Medicare Advantage (MA) and Part D since the Affordable Care Act turned the consumer information tool into the biggest experiment in value-based payment on the planet. There’s little argument Star Ratings is working, and MA quality has improved. The program is being adopted in the ObamaCare Health Insurance Marketplace, and the Medicare Access and CHIP Reauthorization Act (MACRA) included the Quality Reporting System, or Stars for Medicaid, starting in 2019. Then Trump got elected President and appointed Tom Price the Department of Health and Human Services (HHS) Secretary. Could they pull out the scalpels for Star Ratings?
It’s possible, even likely, we will see some important changes to Star Ratings during the Trump/Price Administration. Price is a cranky crusader for lessening regulatory and reporting burdens on physicians, and he’s absolutely right about MA plans shifting the paperwork burden to providers in recent years. There’s also a strong argument that at almost 50 measures, Star Ratings has become unmanageable and needs to be pared back.
If we’re lucky, we’ll see removal of the “easy” measures that create lots of hassle for providers despite their being part of standard clinical pathways and little return on investment being generated by their inclusion as MA Star Ratings measures. These would include measures like body mass index assessment, nephropathy screening for diabetics, and maybe flu vaccines.
We could see removal of breast cancer/colorectal cancer/diabetic eye exams since these cause crazy hassle factors for primary care providers (PCPs), who have no financial upside to schedule these appointments which occur outside of their own practice. We would also expect Price to get rid of measures on beneficiary physical activity, reducing fall risks, and urinary incontinence – these drive doctors absolutely nuts when MA plans request support, as the fixes often come far outside their offices.
Many of these measures are certainly solid Healthcare Effectiveness Data and Information Set (HEDIS®) fixtures and can be a good directional barometer of health improvements. However, most plans’ Star Ratings programs only provide the PCP a few bucks to try to coordinate these screenings for members, and generally the limited dollars offered to PCPs aren’t worth their effort, making them ripe for a crusader like Price to cut them.
There are also some unintended downstream consequences of these measures, fueling arguments to retire them:
- By sending lower-income patients to specialists to get these appointments, the PCP often “uses up” the patient’s willingness to see doctors during a limited period of time, uses up the patient’s transportation benefit allotment, and, in some cases, uses up the amount of money the patient has available to support their health in any given calendar year.
- If the PCP sends a hypertensive diabetic to three specialists to get a mammogram, colonoscopy, and retinal eye exam to support an MA plan’s Star Ratings, the patient may be so tired of seeing doctors, the PCP doesn’t get the patient back into his or her own office for a while. This, in turn, erodes the opportunity to improve outcomes measures and potentially Consumer Assessment of Healthcare Providers and Systems (CAHPS®) and adherence measures.
- For Physical Activity, Fall Risk, and Urinary Incontinence, there is actually a strong, evidence-backed medical loss ratio connection. However, if CMS were to remove these as Star Ratings measures, the best plans in the nation would simply roll out their own efforts in these areas to highly-targeted populations. As Price sees it, why mandate when voluntary efforts are clearly in the stakeholders’ interest?
Medications will likely be a sticking point for Price. Almost no plans provide effective medication information to truly help providers manage polypharmacy issues with their patients. Most MA plans just let their Pharmacy Benefit Manager throw huge volumes of faxes at docs regarding medication Star Ratings measures. Adherence measures and the high-risk medications measures may also be in jeopardy. Doctors hate when health plans question their prescribing habits, and loathe adherence because it’s so far outside the physician’s control, and plans generally provide inadequate monetary incentives to incent high performance.
As a physician, we expect Price to keep the outcomes measures, which reinforce the role of the physician. Ideally, a heavier focus on all or some of the CAHPS® measures, all of the outcomes measures (A1c/blood pressure control, all-cause readmissions), and the two triple-weighted Health Outcomes Survey measures (improving physical/mental health) would help plans focus their attention, minimize provider burden, and truly help focus on controlling longer-term costs by improving health.
The Centers for Medicare & Medicaid Services (CMS) Administrator nominee Seema Verma’s confirmation hearing is this week, and she is expected to be approved quickly. Once she’s seated at CMS, we’d expect to see some of these changes to Star Ratings announced relatively quickly so they may be factored into MA bids in June. Strap on your track shoes, and try to keep up.
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