Apples to Apples: Why special needs and dual-eligible plans need their own CMS Star Ratings System

April 15, 2014 § 2 Comments

By Lawrence Gottlieb, MD, MPP, Chief Quality Officer, Commonwealth Care Alliance

At Commonwealth Care Alliance, we operate in a challenging environment in which the quality of our care and services is appropriately scrutinized by the Centers for Medicare & Medicaid Services (CMS) and MassHealth in order to assure that we are providing high quality to our members.  For Senior Care Options, this is done at the federal level by CMS through the Five Star Quality Ratings System, which measures the quality of care and services we deliver and compares us to other health plans.

Bias in the CMS Star Ratings system
The CMS system is unfairly biased against plans like ours that serve primarily dually eligible individuals. For example, for the 2013 CMS Star Ratings, 23 Fully Integrated Dual Eligible Special Needs Plans received CMS Star ratings. Only two – Commonwealth Care Alliance and Health Partners Senior Health Options (Minnesota) – received 4.5 stars. To get those stars, Commonwealth Care Alliance and Health Partners competed against hundreds of plans that serve less vulnerable populations.

Under the CMS system, there is a whole set of characteristics for special needs plans and dual-eligible plans for which the “vanilla” approach to measuring quality and comparing plans doesn’t fairly assess the quality of care and services. There are only a few measures in the CMS measure set that are particularly relevant to the special needs and dual-eligible populations, populations that may have large numbers of individuals that are very elderly, frail, have significant physical or developmental disabilities, severe mental illness, and who  face significant socioeconomic challenges.

For the CMS Five Star Quality Rating System to provide a level playing field for special needs plans and dual-eligible plans, “risk adjustment” of results for certain socioeconomic and population variables measures is required.

Negative impact on dual-eligible and special needs plans
Recent reports have concluded that the current “apples to oranges” CMS rating system could have a significant negative impact on dual-eligible and special needs plans and the people they serve. In general, lower star ratings result in lower payments. Lower ratings could mean that benefits and services available to members may be lowered. Lower ratings may also force plans to stop serving these groups all together, leaving that population with fewer choices for their health care.

SNP Alliance, ACAP, and others advocate for change
As a plan devoted to serving the most frail patients – socioeconomically, functionally, and medically –and as a plan with a top quality rating, Commonwealth Care Alliance is in a good position to push for changes that promote the best care, and the best access to care, for duals.  Working with similar plans and programs, we have been developing and advocating for proposals to assure that CMS appropriately measures the quality of care that we deliver.  Organizations such as the SNP Alliance and the Association for Community Affiliated Plans (ACAP) are among the groups advocating for changes to the CMS quality rating system.  Significantly, the National Quality Forum has recently entered the debate with the release of its recent report taking the position that socio-economic factors be considered in quality ratings.

A separate CMS ratings system
Although many solutions to the ratings system are being discussed, we believe that dual-eligible and special needs plans should be rated separately from Medicare Advantage plans that serve wealthier and healthier members. This new system should both risk adjust for population differences in key socioeconomic status variables and include measures that target important aspects of caring for our unique populations, like transitions of care management,  behavioral health and primary care integration,  and appropriate us of long-term services and supports. There should also be more measures specific to the most prevalent chronic conditions of members of special needs plans and dual-eligible plans.

“Apples to apples” comparison will ensure that plans are evaluated on how well they are serving their members and help promote and protect access to high quality care for the patients who need it most. Getting this right in the Senior Care Options program will also build an important foundation for quality measurement in the new duals demonstrations nationwide.

 

 

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