Do rankings punish Medicare plans for disadvantaged patients?

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Federal rankings of Medicare Advantage plans may unfairly penalize those that enroll a disproportionate number of non-white, poor, and rural Americans, a new study shows.

Researchers used data that the Centers for Medicare and Medicaid Services collected to measure the quality of care provided in Medicare Advantage plans, and adjusted performance rankings for race, neighborhood poverty level, and other social risk factors. After the adjustments, plans serving the highest proportions of disadvantaged populations improved considerably in the rankings.

The findings show that existing Medicare Advantage plan rankings may not accurately reflect the quality of care a given plan’s enrollees receive, says Amal Trivedi, an associate professor of health services, policy, and practice at Brown University and senior author of the paper in Health Affairs.

“Policymakers have focused a lot of attention on measuring quality and rewarding better performance among health plans and providers,” Trivedi says. “But in order for these quality assessments to be accurate, they need to take into account the characteristics of the populations that are served.”

Medicare Advantage is a newly popular option among Americans who qualify for Medicare, according to statistics from CMS. Before the 21st century, almost everyone opted for traditional Medicare, which allowed beneficiaries to visit any medical professional they wanted.

But today, almost a third of those who qualify for Medicare choose the more affordable Medicare Advantage option. While patients who use Medicare Advantage are restricted to specific networks of doctors, they’re also able to compare dozens of plans and select the best one for their needs based on rankings, cost, and other factors.

For the last decade, Trivedi says, CMS rankings have measured a plan’s quality by examining how well its health care providers perform in about 30 categories, including customer service, efficiency in processing claims and appeals, disease screening rates, and patients’ body mass indexes.

“If you live somewhere rural and have a low-paying job, you have fewer healthy choices near you, and they’re often too expensive to consider.”

Researchers adjusted for socioeconomic disadvantage in just three of those categories—blood pressure control, cholesterol control, and diabetes control—and found that many lower-ranked plans suddenly moved substantially higher in the rankings.

Lead author Shayla Durfey, a third-year medical student in the primary care-population medicine program at the Warren Alpert Medical School, says she and colleagues chose to adjust the data in those three categories because previous literature has shown that disadvantaged populations disproportionately suffer from uncontrolled high blood pressure, high cholesterol levels, and diabetes.

“To control diabetes, for example, you need things like good health literacy, access to healthy foods, and access to money that buys healthy foods,” Durfey says. “If you live somewhere rural and have a low-paying job, you have fewer healthy choices near you, and they’re often too expensive to consider.”

Currently, CMS rankings account for just two risk factors: dual eligibility—which indicates that someone qualifies for both Medicare and Medicaid—and disability. While health scholars have long debated which CMS categories should be adjusted to account for social risk, many experts agree CMS should do more, Durfey says.

“The adjustments CMS uses do not fully account for true measures of socioeconomic status, such as income level, education and employment. These factors have been shown to play a huge role in a person’s lifetime health.”

Accurate quality rankings are important, because CMS gives plans an incentive to compete against each other, Trivedi says. A plan that receives a five-star rating is rewarded with a sizeable payment bump. A plan that gets a one-star rating, on the other hand, is penalized: All of its enrollees receive letters encouraging them to switch to better plans.

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If plans notice a connection between their low rankings and their socioeconomically disadvantaged enrollees, they’ll have little incentive to continue serving the underserved, he adds.

“Medicare plans can’t deny coverage to anyone with a pre-existing condition, but they can operate in areas that are more affluent or have healthier, less disadvantaged populations, leaving poor and rural populations with fewer and fewer options,” he says.

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While the researchers say it’s still unclear what precise set of adjustments will lead to the most equitable CMS rankings, they hope the agency soon takes action one way or another. If one thing is clear, it’s that determining whether and how to adjust Medicare Advantage plan quality measures for sociodemographic factors is critically important to accuracy and equitable payment.

“There needs to be a lot more research on the topic, especially as we move toward a value-based payment system where dollars are attached to clinical performance,” Trivedi says. “We need to be sensitive to the effects of these policies on disadvantaged populations and the providers that serve them. That’s really the take-home message.”

The National Institutes of Health supported the work.

Source: Brown University