Rachel Reid, MS 1 ; Benjamin Howell, PhD 2 ; Partha Deb, PhD 2 ; William Shrank, MD MSHS 2 1 University of Pittsburgh School of Medicine, 2 CMS Innovation Center AcademyHealth 2012 Annual Research Meeting
CMS Publishes Star Ratings Reflecting Medicare Advantage Plan Quality Available to beneficiaries via the Medicare Plan Finder website and other sources, including plans marketing Cl Calculated l dbased on information from: Surveys (CAHPS, HOS) HEDIS Measures Other administrative data (e.g., complaints, appeals, audits, customer service)
2011 Medicare Advantage Star Ratings Though they have evolved since 2008, more recently Star Ratings issued on 5 star scale at 0.5 star intervals Overall Star Rating created for Medicare Advantage & Prescription Drug (MAPD) Plans Combined Part C & D Components 3 MAPD contracts received 5 stars No MAPD contracts received fewer than 2.5 stars Some plans are unrated
Important to Understand Implications of Star Rating Program It is clear that Star Ratings matter to the plans Owing to bonuses paid on the basis of Star Ratings starting in 2012. However, it is not known whether Star Ratings matter to beneficiaries. i i Study Aim: To assess the association between Star Ratings and Medicare Advantage enrollment choices.
Cross sectional sectional Study of 2011 MAPD Plan Enrollment Choices 2011 MAPD enrollments of 2 groups shopping for plans: 1. 1 st time Medicare Advantage Enrollees 2. Those Switching Between MAPD Plans Focused on MAPD enrollments, represent majority of Medicare Advantage enrollments Matched beneficiaries with choice set of available plans
Conditional Logistic Regression Model Association between Star Rating and Enrollment Included Star Rating 2 ways 1.Star Rating Itself 2.Rating Relative to Other Plans 1 st Time Enrollees plan s rating is highest available Switching Plans plan s rating is prior plan Accounted for beneficiary characteristics: Age, race, gender, low income, rural vs. urban residence, region Controlled for plan characteristics Plan type, benefit generosity, sponsor organization s market share
Characteristics of Enrollees 1 st Time Enrollee (%) (N = 952,352) Switching Plans (%) (N = 322,699) Age Sex Race/ Ethnicity Low Income Urban/Rural Region N, Plans in Choice Set Less than 64 21.4 Less than 66 17.4 64 65 40.5 66 70 33.7 66 70 17.7 71 76 25.0 71 or Greater 20.4 77 or Greater 23.9 Male 45.6 Male 43.8 Female 54.4 Female 56.2 White 73.7 White 75.2 Black 10.4 Black 10.4 Hispanic 9.4 Hispanic 10.3 Oh Other 6.5 Oh Other 4.1 No 88.9 No 89.5 Yes 11.1 Yes 10.5 Urban 82.9 Urban 87.0 Rural 17.1 Rural 13.0 Northeast 18.2 Northeast 23.1 South 38.0 South 37.5 Midwest 19.3 Midwest 17.6 West 24.6 West 21.8 10 or Fewer 32.4 10 or Fewer 30.8 11 20 36.3 11 20 39.3 21 or More 31.3 21 or More 29.9
Star Ratings of Plans in Choice Sets & Actually Chosen 1 st Time Enrollees Plan Star Ratings Rating Relative to Other Plans 100% 90% 5 Stars, 0.4% 4 4.5 Stars, 11.6% 100% 90% Top Rated Plan, 19.4% 80% 80% 70% 70% 60% 50% 3 3.5 Stars, 53.7% 60% 50% Within 0.5 Stars of Top Plan, 46.2% 40% 40% 30% 20% 2.5 Stars, 14.3% 30% 20% Oh Other Plan, 14.3% 10% Unrated, 20.1% 10% Unrated, 20.1% 0% Plans in Choice Sets Plans in which Enrolled 0% Plans in Choice Sets Plans in which Enrolled
Star Ratings of Plans in Choice Sets & Actually Chosen 1 st Time Enrollees Plan Star Ratings Rating Relative to Other Plans 100% 90% 80% 5 Stars, 0.4% 5 Stars, 0.8% 4 4.5 Stars, 11.6% 4 4.5 Stars, 18.8% 100% 90% 80% Top Rated Plan, 19.4% Top Rated Plan, 35.1% 70% 70% 60% 50% 40% 3 3.5 Stars, 53.7% 3 3.5 Stars, 62.5% 60% 50% 40% Within 0.5 Stars of Top Plan, 46.2% Within 0.5 Stars of Top Plan, 36.7% 30% 20% 10% 0% 2.5 Stars, 14.3% 2.5 Stars, Unrated, 8.0% 20.1% Unrated, 10.0% Plans in Choice Sets Plans in which Enrolled 30% 20% 10% 0% Oh Other Plan, 14.3% Other Plan, 18.2% Unrated, 20.1% Unrated, 10.0% Plans in Choice Sets Plans in which Enrolled
Star Ratings of Plans in Choice Sets & Actually Chosen Switching Plans Plan Star Ratings Rating Relative to Prior Plan 100% 90% 80% 5 Stars, 0.1% 4 4.5 Stars, 9.8% 100% 90% 80% Higher than Prior Plan, 20.6% 70% 60% 3 3.5 Stars, 55.2% 70% 60% Equal to Prior Plan,,30.3% 3% 50% 50% 40% 30% 20% 2.5 Stars, 14.1% 40% 30% 20% Lower than Prior Plan, 28.3% 10% Unrated, 20.8% 10% Unrated, 20.8% 0% Plans in Choice Sets Plans in which Enrolled 0% Plans in Choice Sets Plans in which Enrolled
Star Ratings of Plans in Choice Sets & Actually Chosen Switching Plans Plan Star Ratings Rating Relative to Prior Plan 100% 90% 80% 5 Stars, 0.1% 5 Stars, 0.2% 4 4.5 Stars, 9.8% 4 4.5 Stars, 12.9% 100% 90% 80% Higher than Prior Plan, 20.6% Higher than Prior Plan, 25.0% 70% 60% 50% 3 3.5 Stars, 55.2% 3 3.5 Stars, 67.2% 70% 60% 50% Equal to Prior Plan,,30.3% 3% Equal to Prior Plan, 37.4% 40% 30% 20% 10% 0% 2.5 Stars, 14.1% 2.5 Stars, Unrated, 6.7% 20.8% Unrated, 13.0% Plans in Choice Sets Plans in which Enrolled 40% 30% 20% 10% 0% Lower than Prior Plan, 28.3% Lower than Prior Plan, 24.6% Unrated, 20.8% Unrated, 13.0% Plans in Choice Sets Plans in which Enrolled
1st Time Enrollees: Average Marginal Effect of Star Ratings on Enrollment 1 Star Increase in Rating Highest Rated Plan Available 16.0% 14.0% 2.0% 12.0% 10.0% 1.9% 1.6% 0.2% 5.7% 1.7% 1.9% 8.0% 1.6% 2.2% 6.0% 4.0% 9.5% 2.5% 12.4% 9.2% 7.4% 11.5% 2.6% 7.9% 9.9% 10.3% 3.8% 9.7% 7.3% 2.0% 5.2% 4.6% 4.2% 0.0% 1.5% 2.0% Overall < 64 64 65 66 70 71+ White Black Hispanic Other Urban Rural No Yes Age Race/Ethnicity Urban/Rural Low Income Status
Switching Plans: Average Marginal Effect of Star Ratings on Enrollment 1 Star Increase in Rating Rating at Least as High as Prior Plan 16.0% 14.0% 12.0% 10.0% 8.0% 8.3% 7.2% 6.0% 6.8% 9.0% 6.3% 6.4% 6.0% 5.0% 6.3% 4.3% 4.0% 2.0% 0.0% 2.0% 4.4% 3.6% 4.9% 4.1% 4.6% 4.8% 3.6% 1.9% 6.7% 2.1% 2.4% 1.5% 4.7% 2.2% 4.5% 3.3% Overall <66 66 70 71 76 77+ White Black Hispanic Other Urban Rural No Yes Age Race/Ethnicity Urban/Rural Low Income Status
Summary Positive association between publicly reported Star Ratings and enrollment in Medicare Advantage plans While cannot attribute association to Star Rating program itself, observed preferential enrollment in higher quality plans is reassuring Key subgroups of beneficiaries enrollments are less strongly associated with Star Ratings: Black, low income, rural, and the youngest beneficiaries
Limitations Given the study design, of course, cannot know whether more highly rated plans would have had preferential enrollment for another reason, absent the Star Ratings Assess only 1 year of enrollments Presume decision to enroll or switch in the first place was made absent consideration of plans available Beneficiaries may be more likely to choose Traditional Medicare, in lieu of Medicare Advantage, if characteristics of plans available are unappealing
Implications Increased enrollment associated with differences in quality, as measured via publicly reported Star Ratings : From plan perspective, findings may create additional incentive to improve plans quality From beneficiary or agency yperspective, p continued evolution of Star Rating methodology may be warranted Findings are encouraging and may help to build business case for quality in Medicare Advantage market Populations for whom Star Ratings are less associated with enrollment Populations for whom Star Ratings are less associated with enrollment represent potential targets for outreach or education
Thank You! Questions? reid.rachel@medstudent.pitt.edurachel@medstudent edu