Thoughts on the CMS Medicare Quality “Five-Star” Rating System

CMS Medicare Quality "Five-Star" Rating System
CMS Medicare Quality “Five-Star” Rating System
This past October, the Centers for Medicare & Medicaid Services (CMS) announced two Medicare Quality Improvement Initiatives. I spent part of Thanksgiving weekend analyzing the most recent Star Quality bonus scores and trying to figure out where this program is going and what value we will get from it as an industry.  Much of the work that I am doing these days is focused on data.  I look at that through the prism of health plan operations where I spent a number of years.

CMS points out the overall improvement in quality which they position as the result of focusing, and incenting quality.  I agree that putting funding behind a quality program was a valuable strategy to motivate the industry.   This has not always been the case, in fact a former colleague who related a common dialog previous to this program:

  1. He would present a quality initiative to executive management
  2. They would nod politely and say, “Yes, of course we are interested in quality!”
  3. The conversation would continue until the cost of the program was disclosed.

The faces would change, and the response was, “Well, yes, quality is important, but funding is tight right now.  We need to focus on programs with a clear ROI”.

Thankfully the Star program has given quality initiatives a clear ROI – for which we are all grateful!

The other dynamic which is positive is that Medicare Advantage has provided a testing ground for new programs, largely the result of ACA.  Programs very similar to the Star program are part of the ACO program and the marketplace membership.  Risk Adjustment is being fitted to meet these programs also.  Private insurance will likely borrow similar structures to insure quality and fair compensation in their various risk sharing arrangements.  MA is a significant subset of the population and is providing an excellent sandbox for these initiatives while improving the quality of care that our senior population receives.

My concerns are around the cultures and mission of those plans who are struggling to get to the magic four star level where they will receive the bonus dollars.

Having worked in a health plan for almost nine years, and continuing to interact with my current customers, has shown me the dedication of the staffs that work in these plans.  One of my most rewarding experiences was leading the call center for the Medicare population.  I was humbled each day by the caring and patience the reps on the phones showed to the senior population.  I have also seen the dedication of clinical staffs to insuring the care for members is carefully coordinated and that their dignity and wishes were always respected.  I sincerely hope that plans with a clear mission find the right tools and supports to improve their ratings to the point where they receive the additional funding to maintain their viability and continue to serve their members and the medical community.  I am sure that there are poor quality plans out there, and I agree that they should be eliminated.  But I am also rooting for the plans with a mission who are striving to be a bit better.

Comments