By Aparna Higgins, Mark McClellan
Health Affairs Blog. August 15, 2018
The secretary of the Department of Health and Human Services (HHS) recently highlighted value-based transformation as one of the department’s top four priorities, with an emphasis on “putting the consumer in charge, letting them determine value.” While definitions of value may vary based on beneficiary preferences, objective, reliable, and meaningful quality and cost measures are important components of individuals’ and health care providers’ assessment of value. However, obtaining such measures of value in practice has proven challenging. To address concerns with the usefulness of and burden of implementing the quality measures currently in use, the Centers for Medicare and Medicaid Services (CMS) launched its Meaningful Measures initiative. Its first task is to review the extent to which existing quality measures are fulfilling the needs of consumers and providers and identifying priority gaps.
The success of APMs and patient engagement in care more generally is inextricably linked to the quality of the measures that are used in these APMs, and the burden versus benefit of collecting these measures. As CMS seeks to further evolve payment models, it is important for policy makers to consider what kinds of measures we would want to invent that can then be tied to a set of alternative payments. The approach presented in this blog post can serve as a starting point for a dialogue on this topic. Many of the concepts presented here need further discussion, refinement, and development. The Meaningful Measures initiative can provide a platform for such discussion and help launch a re-engineering of measures and measurement.
Assessing the Medicare Advantage Star Ratings
By Dan Jamieson, Monisha Machado-Pereira, Stephanie Carlton, and Cara Repasky
McKinsey & Company, July 2018
Every October since 2009, the Centers for Medicare and Medicaid Services (CMS) has released comprehensive data on Medicare Advantage (MA) health plan performance through its Star Ratings program. The program’s goals are to incentivize health insurers to improve their MA plans and encourage consumers to enroll in high-quality plans. To investigate whether these goals are being met, we analyzed CMS’s data for 2018 and previous years.
On average, the plans’ scores have risen substantially, both overall and on the 22 individual quality measures that have been used consistently since the program’s inception.
The overall scores are based on the scores assigned to specific measures, many of which have been modified since the program’s inception. However, 22 of the measures have been used consistently since 2009. (We call this set the consistent measures.) After calculating the enrollment-weighted average scores for each of the consistent measures, we found that all but two have risen over time.
From the table of measures included in all Star Ratings years:
Improving or maintaining physical health
3.4 – Weighted-average Star Rating, 2009
2.8 – Weighted-average Star Rating, 2018
By Don McCanne, M.D.
These days it seems that the policy community is deeply involved in issues related to quality, accountability, incentives, and the such, through value-based alternative payment models such as accountable care organizations or systems such as Medicare Advantage plans. Is optimal care of the patient being lost in all of this?
Recently there has been some celebration of the success of the Star Ratings used for the private Medicare Advantage plans, supposedly showing that quality is improving. If you look at the McKinsey report, you will find the scores for 22 quality measures used during the last decade. The plan providers have been told repeatedly what will be measured; the measurements were taken, and the Star Ratings were assigned. It should be no surprise that the scores improved. It’s not even an open-book test; it’s a one-page cheat sheet with all the answers.
What is alarming is that the most important score – the one for “improving or maintaining physical health” – deteriorated! While the providers have been busy making sure that they scored well, the patients have been neglected (as anyone who has watched their health care professional spend their contact time staring at the computer can attest to).
Yet the governmental and private members of the policy community plow on with nebulous goals of imposing accountability and quality through alternative payment models such as accountable care organizations. But look at the hope for the future as described by Aparna Higgins and Mark McClellan:
“It is important for policy makers to consider what kinds of measures we would want to invent that can then be tied to a set of alternative payments”… though “Many of the concepts presented here need further discussion, refinement, and development.”
We’re moving forward with policies that we haven’t even invented yet?
My twin and I started in private practice the same month that Medicare and Medicaid were implemented, joining our father and older brother. To them it was almost like a miraculous change. We could just take care of the patients and not worry about other issues such as how payment would be made.
Alas, it didn’t last. Insurers were granted the right to contract with physicians. Managed care moved in with a vengeance. Medicare began its march to privatization with the opening of the Medicare Advantage market. And now we face MIPS, APMs, ACOs, and, according to Higgins and McClellan, whatever else the policy makers “would want to invent” even if lacking in “further discussion, refinement, and development.”
Let’s get back to the original precepts of Medicare: removing financial barriers to essential health care services; place the patients first. Medicare does have some problems that we can easily fix, so let’s do that, include everyone, and then move forward with health care that actually will maintain and improve physical health. The McKinsey report shows that we’re not doing that now. But we don’t need to reinvent the traditional Medicare program, we just need to fix it.
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