Medicare Star Ratings: Challenges for Health Plans Serving Low-Income Members. Joyce Chan VP, Clinical Performance Healthfirst

Size: px

Start display at page:

Download "Medicare Star Ratings: Challenges for Health Plans Serving Low-Income Members. Joyce Chan VP, Clinical Performance Healthfirst"

Bartholomew Douglas
7 years ago
Views:

1 Medicare Star Ratings: Challenges for Health Plans Serving Low-Income Members Joyce Chan VP, Clinical Performance Healthfirst May 2015

2 About Healthfirst A one-million-member not-for-profit HMO sponsored by New York not-forprofit and public hospitals and healthcare systems Who We Are Unique model offering financial risk assessments to provider systems Global financial risk arrangements based on a member s selection of PCPs who are clinically aligned with the hospital Capitation and financial surplus-sharing with selected PCPs Pay-for-performance (quality incentive) programs cover 85 percent of members Large network of health centers, community physicians, and hospitalbased clinicians Strong community roots Nine community-based offices across New York City and Long Island, with on-site member services Active partnerships with churches, housing projects, and other community-based organizations Page 2

3 Our members are underserved 1.1 million members in downstate New York 129,000 Medicare Advantage Prescription Drug (MAPD) 80% receive Extra Help with Part D premiums 60% are dually eligible for Medicare & Medicaid 925,000 Medicaid/ Child Health Plus 15,000 Medicaid Managed Long Term Care 40,000 Qualified Health Plan (Exchange) Diverse and challenged Medicare population 53% have primary language other than English 46% Hispanic, 36% Black, and 9% Asian, 9% other 70% have less than the equivalent of a high school education 2 Healthfirst Medicare Members Measure 1 HF National 4+ Chronic Conditions 45% 38% Positive Depression Screen 20% 11% General Health: Fair or Poor 48% 26% Self-Reported Pain : % 28% We are the first health insurance experience for many of our members 1) Medicare Health Outcomes Survey, Cohort 14 Performance Measurement Report, July 2014, Centers for Medicare and Medicaid Services 2) Ibid Page 3

We earned 4 stars on the 2015 Star Ratings Discussion Points Because we are in 95% counties, we must receive the 5% Star bonus to ensure our: - Viability as a plan - Ability to give members needed

4 We earned 4 stars on the 2015 Star Ratings Discussion Points Because we are in 95% counties, we must receive the 5% Star bonus to ensure our: - Viability as a plan - Ability to give members needed services and support MA plans with >50% low income member penetration perform a full half-star below other plans. 1 - This half-star difference is critical because the Star Ratings bonus is awarded only upon attainment of 4 Stars it is all or nothing. - CMS should adjust Star Ratings to account for the effects of low socioeconomic status (SES) on Star performance The Star Ratings system needs to be adjusted for socioeconomic status to prevent differential MA funding of low income versus more affluent communities 1) Weiss, H., & Pescatello, S. (2014, September 22). Medicare Advantage: Stars System s Disproportionate Impact On MA Plans Focusing On Low-Income Populations. Retrieved from Page 4

5 Star Ratings and Socioeconomic Status (SES) A significant body of research demonstrates that SES (e.g., income, education, stable housing) is significantly correlated with performance on quality measures. 1,2 Low-SES beneficiaries are consistently more complex to manage than non-dual populations and are less likely to comply with preventative care screenings and exams. Lower baseline levels of health, combined with increased complexity, present significant challenges when trying to replicate the results for more affluent members, despite considerable investment in care coordination activities. The Star Ratings system undervalues the achievements of plans focused on low-ses beneficiaries by failing to account for the impact of SES on plan performance. 1) Young, Gary J., Nathaniel M. Rickles, Chia-Hung Chou, and Eli Raver. Socioeconomic Characteristics Of Enrollees Appear To Influence Performance Scores For Medicare Part D Contractors. Health Affairs, 33.1 (Jan 2014): ) Hu, Jianhui, Meredith D. Gonaahn, and David R. Nerenz. Socioeconomic Status and Readmissions: Evidence from an Urban Teaching Hospital. Health Affairs, 33.5 (May 2014): Page 5

6 Focus: Medication Adherence Background Medication Adherence measures the percent of members who adhere to their drug therapy Healthfirst performance on all 3 MA measures improved steadily since 2010 by 6 points on MA-D and 9+ points on MA-C and MA-H Healthfirst s average Star Rating on MA remains low at 2.3 Stars Barriers Cost non-lis members earn too much to qualify for a subsidy, but do not earn enough to comfortably pay all of their co-pays Safety Unstable housing and high crime result in members not having a safe place to keep medications or have them delivered Cultural Beliefs Reliance on traditional remedies; fatalistic belief that medicine will not help Health Literacy e.g., limited understanding of medication measurements like milliliters Interventions Formulary Changes: zero dollar copays for all generic adherence medications Intensive outreach, including reminder letters / calls and counseling Close partnerships with physicians and pharmacists MA-D = Medication Adherence for Diabetic Medications MA-C = Medication Adherence for Cholesterol MA-H = Medication Adherence for Hypertension Page 6

7 Focus: Osteoporosis Management Background Osteoporosis Management measures the percent of female members aged 67 and older who suffered a fracture and, within 6 months, had either a bone density test or filled a prescription to treat or prevent osteoporosis Healthfirst performance was only 26% in 2013, with LIS member compliance of 25% compared to non-lis member compliance of 29% Barriers Cultural Beliefs e.g., Black women have naturally strong bones Health Literacy e.g., Any radiation is dangerous Clinical Complexity e.g., Forgetfulness, especially among members with behavioral health issues Interventions In-home bone density tests doubled our compliance rates However, we still only expect to earn 3 stars on this measure, which suggests that even the most intense and effective interventions will still not close the performance gap for plans serving low income members Page 7

Low-Income Beneficiaries and Star Ratings Summary Star Rating performance appears to be related to the socioeconomic status of members - characteristics that are beyond plan control.

8 Low-Income Beneficiaries and Star Ratings Summary Star Rating performance appears to be related to the socioeconomic status of members - characteristics that are beyond plan control. Medicare s most vulnerable beneficiaries will lose the services and resources necessary to improve their care and outcomes if the high-quality plans that serve them are not fairly evaluated in the Star Ratings system Page 8

9 Recognition of Low Income Issues & Stars CMS CMS is evaluating whether the Star Ratings are impacted by the percentage of dual / low income members in a plan Issued RFI (Request for Information) in Fall 2014 for analyses demonstrating that dual status causes lower Star Ratings Conducted internal research on 19 out of 46 Star measures Collaborating with the Assistant Secretary for Planning and Evaluation (ASPE) as part of the IMPACT Act to examine the effect of individuals socioeconomic status on the Star ratings Legislators Bipartisan Senate letter sent to CMS in Feb 2015; 40 Senators signed letter led by Sens. Portman and Nelson Bipartisan House letter sent to CMS in Nov 2014; 32 Members signed letter led by Reps. Black and Blumenauer Measure Owners & Approvers National Quality Forum (NQF) published a 2014 report Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors ; subsequently established standing Disparities Committee and trial period for developing and evaluating sociodemographic status (SDS) adjusted measures Pharmacy Quality Alliance (PQA) established advisory group focused on SDS risk adjustment for PQA-endorsed Star measures Industry Industry workgroups are exploring potential solutions to address the Star Ratings disparities that are related to the SES/SDS of plans memberships Page 9

10 Proposed Refinements to Star Ratings Risk adjust relevant measures for sociodemographic status (SDS) Decrease weighting of measures most influenced by socioeconomic factors Adjust Star Ratings by giving credit to plans that reduce healthcare disparities (i.e., serve large proportion of low income members and achieve certain Star performance levels) Divide up the 5% Star Bonus into smaller amounts that can be earned for achievement, improvement, etc. And others Page 10

11 For more information Joyce Chan Vice President, Clinical Performance Healthfirst (212) Page 11

Health System Reform & the Quality of Healthcare

Health Systems Reforms, Quality & Medicare in Puerto Rico Roberto Pando, MS, JD Strategy VP MCS Health System Reform & the Quality of Healthcare Contents (1)The Healthcare Context in Puerto Rico (2)Health