Putting the Patient in the Center: Star Ratings Congress for Medicare Advantage Plans

As I like to say, Medicare Advantage (MA) is one of the best kept secrets in Washington.  When it comes to creating better health, providing better health care, and lowering costs, MA plans are on a path to creating value, and a model for the future of our health care system.

Let’s start with some basics.

Today, one in four people with Medicare are enrolled in a Medicare Advantage plan.  In fact, as of January of this year, 12.8 million beneficiaries were enrolled in an MA plan. The number of seniors enrolling in MA plans is rising at a rate of 5 to 10 percent a year.  And the number of plans participating in the program is also rising.

Improving the quality of care and rewarding value in MA has long been a goal of Medicare policy experts.  And the drive toward these goals began nearly a decade ago when Congress began to consider policies to move MA – and the rest of the Medicare program — in this direction, including:

  • Under the Medicare Modernization Act of 2003, the Institute of Medicine (IOM) was directed to evaluate ways to improve quality and value. The IOM issued a 2006 report, “Rewarding Provider Performance: Aligning Incentives in Medicare,” that recommended Medicare begin to test pay for performance in the MA program.
  • Beginning in 2004, the Medicare Payment Advisory Commission (MedPAC) recommended that Congress establish a quality incentive payment policy for Medicare Advantage (MA) plans, reflecting its view that “one of Medicare’s most important goals is to ensure that beneficiaries have access to high quality health care.” With their history of measurement and accountability, private plans were a logical starting point for quality-based payments.
  • The Affordable Care Act (ACA) incorporated significant changes to the MA program, including a quality incentive program based on established quality metrics and a star ratings system, to start in 2012. At the same time, Congress established or extended quality reporting and payment requirements for hospitals, physicians, and other providers serving Medicare patients.

What we have seen is steady improvement on a wide range of quality measures year after year.  In a number of key clinical areas, Medicare Advantage plans perform at a higher level than their commercial counterparts.

I have the honor of working with a group of health plans that embraced the challenge Medicare laid out by providing high quality care to hundreds of thousands of seniors.  Some 98 percent of Medicare beneficiaries enrolled in an MA plan that received a 5-star quality rating from CMS (the highest possible rating) are in ACHP member plans.  In 2011, the National Committee for Quality Assurance (NCQA) ranked 17 ACHP Medicare plans among the top 25 in the country.

But instead of merely reiterating our successes, I’d like to share some of the things that we have learned over many years of pursuing higher quality care, even when the system didn’t provide any financial incentives.  Essentially, putting the patient at the center of care is critical; leadership and systems should be built around this central feature.

This commitment starts at the very top of an organization, meaning that CEOs and their leadership teams must send a clear message to staff, partners and communities that they hold themselves and their organizations accountable to better experiences of care for their patients.  Higher quality also requires systemic thinking, such as building new systems and processes that support safe, effective, patient-centered, timely, efficient and equitable care.  One aspect of this systemic thinking is building a close relationship between health plans and their provider partners – and once again, putting patients at the center.  A commitment to training and culture growth can pull an entire health care system toward a new organizational DNA – one that is all about better health, better health care and lower costs.

There has been some criticism recently about the ACA’s MA star ratings program, which links payment to quality and therefore creates incentives for the Medicare program to actually buy value.  I could offer a slew of statistics reaffirming the benefits of MA and paying for quality, but I think it would be more effective to share a story from one of our member plans, Priority Health in Grand Rapids, Michigan.

“Michael” is a member of Priority Health, and, like many Medicare beneficiaries, Michael suffers from multiple chronic conditions.  In fact, his health history includes diabetes, back pain, congestive heart failure, depression, and chronic obstructive pulmonary disease, among other conditions.

Before he joined an MA plan, Michael did not have a primary care physician, and was socially isolated and experiencing frequent hospitalizations. At the time, he was on a ventilator and his doctors were doubtful that he would recover.

Once he was enrolled in Priority Health’s MA plan, he chose a primary care physician, and a complex care management team worked to address barriers to Michael’s care.  They provided him with counseling on how to manage his chronic conditions. They taught him what he needed to know about his medications, and set up a home telemonitoring program.  As a result, Michael has avoided readmission for nearly ten months. He better understands how to manage his multiple conditions, and is enjoying a much better quality of life.  He even has a girlfriend now.

Health plans like Priority Health focus on quality outcomes, care coordination, and patient engagement. Instead of a long litany of uncoordinated services that run up a huge bill and deteriorate the patient’s quality of life, people like Michael – and there are millions of them in our country today – get the care they need, when they need it, from trained professionals who put the patient at the center of care.

-Patricia Smith
President and CEO, ACHP


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