Study of CMS Star Ratings Finds Discrepancies Between Dual Eligibles, Non-Duals

A significant and growing performance gap exists between dual eligible and non-dual eligible members when it comes to CMS Five-Star Quality rating measures, according to Inovalon, Inc., a leading provider of data-driven healthcare solutions.

The study, titled “The Impact of Dual Eligible Populations on CMS Five-Star Quality Measures and Member Outcomes in Medicare Advantage Health Plans,” found that a significant association exists between dual eligible status and lower performance on specific Part C and D measure Star ratings. The results point to the integral role that income, race/ethnicity, and gender play on the HEDIS— and CMS Part D measures used in the Five-Star rating system.

According to researchers, the gap has widened in reported Star ratings for 2012 and 2013 compared to previous findings. When scored by either the Charlson Comorbidity Index or CMS Medicare Advantage (MA) risk score, dual eligible members were found to be consistently more complex to manage. Additionally, examination of 80 CMS MA contracts indicated that dual eligible members performed worse on nine of the ten Star measures that were investigated.

In addition, when controlling for demographics, socioeconomic characteristics, and severity of illness, researchers found that dual members consistently underperformed in eight of the ten measures investigated, demonstrating a significant performance gap between dual eligible and non-dual eligible members even after adjusting for other important socioeconomic and clinical risk factors.

Other key findings from the report suggest the following:

  • The Five-Star rating system, in its current state, may penalize MA plans serving a high proportion of dual eligible beneficiaries.
  • Lower Star ratings result in lower incentive payments and may lead to reduced services to dual eligibles.
  • There is a need for further research into the benchmarking and refinement of Star quality measures to assure fair comparisons of performance across MA plans serving different populations.

The results were culled from the 11.8 million MA enrollees present within the MORE— Registry. Researchers identified 1,335,709 enrollees in 2011 (16.6 percent dual eligible) and 1,605,644 enrollees in 2012 (16.2 percent dual eligible) from 80 individual CMS contracts who met the study inclusion criteria. Rates for nine Star measures were calculated independently for the dual and non-dual eligible members and then within each of those groups stratifying by various demographic, clinical, and socioeconomic characteristics. In addition a tenth measure, plan all-cause readmission rate (PCR) was calculated using the National Committee for Quality Assurance (NCQA) risk adjustment model for MA members age 65 and older, which controls for chronic conditions and factors impacting likelihood of readmission.

Researchers hope this study will inform future discussions that will improve quality outcomes and care.

Source: Inovalon , October 30, 2013

Formula for CMS Five-Star Quality Population Health Management examines star quality improvement strategies, including this “star czar’s” successful care management efforts that have made it a leader in the five-star space.

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