Quality Ratings

In a sweeping proposed rule for the 2024 contract year, CMS last month took a strong stance on multiple aspects of the Medicare Advantage program, from misleading marketing and prior authorization to quality gains incentivized by the Star Ratings. As plans digest the many changes proposed in that rule, several major unknowns remain that could impact their revenue streams and ability to compete going forward. For our annual series of outlook stories on the year ahead, we asked a range of industry experts to weigh in on how doing business in 2023 might differ from previous years. Here’s the first installment on industry challenges and trends as told to AIS Health, a division of MMIT.

When it comes to chasing high ratings and quality bonus payments to help them stay competitive, Medicare Advantage and Part D plan sponsors this year may be forced to overhaul their current strategies and investments if CMS finalizes a host of recently proposed changes. In addition to implementing a new outlier methodology that will drive up cut points and make it harder for plans to achieve 4 stars next fall, CMS last month issued a sweeping rule proposing policy and technical changes across the MA and Part D programs for contract year 2024. That rule included multiple proposals aimed directly at the stars program, such as the creation of a health equity index for the 2027 Star Ratings and the addition of several new measures to the 2026 Star Ratings.

A little over half of Medicare Advantage Prescription Drug (MA-PD) contracts that will be offered in 2023 received an overall rating of 4 stars or higher, according to Medicare Parts C and D Star Ratings data released by CMS on Oct. 6. As expected, the new ratings reflect a return to normal after adjustments made for the COVID-19 public health emergency (PHE) resulted in a staggering 70% of MA-PD plans earning 4 stars or higher for 2022, compared with 49% of plans in 2021. But as the market becomes more saturated across the country, industry experts are watching closely to see whether recent steps taken by CMS to penalize poor performers will really level-set the market or demonstrate that more changes are needed to ensure members enroll in high-quality plans.

The quality of care and patient experience significantly varies among Medicare Advantage plans with similar monthly premiums, according to an analysis published on Aug. 26 in JAMA Health Forum. The retrospective, cross-sectional study also found that there was only a small mean difference in quality among low- and high-cost plans.

Amelia Haviland, the study’s lead author, tells AIS Health that the results indicate “how little guarantee there is that by paying more you’re going to wind up in a plan with higher quality. You might pick one of the plans that’s well below the mean within that cost tier or much higher.” However, she suggests insurers that offer low-cost Medicare plans can use the findings to show that people can still receive top-notch plans without paying high premiums.

More employers are looking at offering near-site or onsite health clinics to employees and their families, in a bid to improve employee retention, elevate quality of care and better manage medical and pharmacy costs. To optimize these clinic offerings, employers should incorporate high-performing providers and align incentives between patients and primary care physicians (PCPs), say experts who spoke at a recent conference held by the Business Health Care Group (BHCG) of Wisconsin.

According to Mercer’s “Health & Benefit Strategies for 2023” report (see infographic), 17% of large employers said they currently provide onsite or near-site health services to employees, while 12% are planning or considering doing so. The survey was conducted April 26 to May 13, 2022, and included 451 organizations with 500 or more employees.

During a recent hearing held by the House Energy and Commerce (E&C) Committee’s Subcommittee on Oversight and Investigations, lawmakers heard testimony from three federal watchdog agencies on ways CMS can achieve efficiencies in the Medicare Advantage program and improve oversight of MA organizations. But while CMS’s actions were the subject of intense discussion, the agency itself wasn’t present — a point that several lawmakers felt worth repeating, even though CMS claims it was not properly invited.

E&C Chairman Frank Pallone, Jr. (D-N.J.) on June 28 convened the hearing, “Protecting America’s Seniors: Oversight of Private Sector Medicare Advantage Plans,” to “examine the quality of care that America’s seniors are receiving through Medicare Advantage plans and the fiscal sustainability of the Medicare Advantage program,” according to a June 24 memorandum issued to the subcommittee.

With continued emphasis on member experience, several new Part C measures and a directional shift to closing health care inequities, 2022 stands to be a landmark year in terms of changes to Medicare Advantage organizations’ star ratings strategies, industry experts tell AIS Health, a division of MMIT.

“There is so much earth-shattering change on the horizon that most plans are just not thinking about,” cautions Melissa Newton Smith, executive vice president, consulting and professional services with Healthmine, Inc. “We’re worried that COVID took up way too much airtime and that plans have lost sight of the forest through the trees in MA a little bit.”