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Life Health > Health Insurance > Medicare Planning

Medicare quality program grows teeth

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The Centers for Medicare & Medicaid Services (CMS) today added quality ratings to the 2013 Medicare plan selection system.

CMS rates Medicare Advantage plans and Medicare Part D prescription drug program plans using a 5-star system.

CMS is trying to get Medicare Advantage plan managers more interested in the rating program this year by tying about $8.3 billion in Medicare Advantage funding to “quality bonus program” linked to the star rating system. 

Some Republicans in Congress have argued that CMS has no clear authority under the Patient Protection and Affordable Care Act of 2010 (PPACA) to run the program, that the program will lead to CMS making bonus payments to too many health plans, and that CMS created the program simply to buffer health plans against PPACA-related cuts in funding.

In addition to adding star ratings to the database that consumers use, CMS has posted spreadsheets and other documents that give the data used to produce the star ratings

The databases are aimed at health care providers, researchers, Medicare agents and brokers, and others with the ability to handle spreadsheets.

The Medicare Advantage plan database, for example, includes 42 columns of information for 578 plans.

Users can sort the data using variables such as success at controlling the blood pressure of plan enrollees, how quickly enrollees report being able to get an appointment, and how well the plan did at seeing that enrollees received appropriate likely a provider was to have assessed an enrollee’s ability to function.

In connection with measure C25, or consumers’ reports on how quickly they get appointments and care, plans tended to cluster fairly close together.

About 86 percent of the enrollees at the plans that performed best on that indicator said they could get appointments and care quickly. Even at the lowest-performing plans, 62 percent of the enrollees said they could get appointments quickly.

For measure C25, the cut-off for a 1-star rating was 72 percent, and the cut-off for a 5-star rating was just a little higher — 79 percent.

In the column for measure C12, which deals with efforts to assess the ability of enrollees in Medicare Advantage “special needs plans” (SNPs) to function, the two plans with the lowest rating measures had no evidence that any of their SNP enrollees had received the recommended annual functional assessments in 2011. The highest-performing plans reported that 100 percent of their SNP enrollees had received functional status assessments.

To get a 2-star rating on the indicator, a plan had to show that 55 percent to 75 percent of its SNP enrollees had received functional status assessments. To get a 5-star rating, a plan would have had to earn a score over 89 percent on that indicator.

Performance on indicator that could have a direct effect on the likelihood that a patient will suffer from a stroke or other catastrophic condition — C19, which measures the “percent of plan members with high blood pressure who got treatment and were able to maintain a healthy pressure” — also varied widely. 

The 1-star cut-off was just 43 percent for that measure, and the 5-star cut-off was 70 percent.

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