Medicaid Council Reports on Study that Finds Dual Eligibles Can Hurt Medicare Advantage Ratings
January 9, 2014 02:59 PM
Inovalon recently published a study titled “The Impact of Dual Eligible Populations on CMS Five-Star Quality Measures and Member Outcomes in Medicare Advantage Health Plans.” Inovalon collected information on beneficiaries from 80 Medicare Advantage (MA) contracts. Specifically, the study looked at 1.33 million MA enrollees from 2011, and 1.61 million MA enrollees from 2012, comparing the dual population with the non-dual population in each year.
The highlights from the 2012 data are discussed below.
Duals have lower quality measures
Inovalon took an in-depth look at ten CMS Five Star Quality Measures. Five of these were Healthcare Effectiveness Data and Information Set (HEDIS) Admin measures and five were Prescription Drug Event (PDE) measures. These ten measures were chosen as scores can be calculated using available administrative claims data.
The ten measures were:
Breast Cancer Screening;
High Risk Medication;
Medication Adherence for Cholesterol (Statins);
Medication Adherence for Hypertension (RAS antagonists);
Medication Adherence for Oral Diabetes Medications;
Osteoporosis Management in Women who had a Fracture;
Plan All-Cause Readmissions; and
Rheumatoid Arthritis Management.
The study found that dual eligibles scored lower than the non-duals on 9 out of 10 of these quality measures, with the exception of Diabetes Treatment. The only measure that was risk adjusted was Plan All-Case Readmissions, which used the National Committee for Quality Assurance (NCQA) risk adjustment model for MA members aged 65 and older. This adjusted for case mix severity for first time hospital visits. These factors included: age, comorbidities, discharge condition, gender, and presence of surgeries.
Lower scores on quality measures have significant repercussions. The star rating system forms a basis for a pay-for-performance element of MA, as plans that obtain at least three stars receive higher payment rates. According to John Gorman, an insurance consultant, plans can earn anywhere from $15 to $50 per month per enrollee per additional half star earned. Therefore, lower star ratings translate to no bonuses. Plans are denied much needed funds to administer medically complex enrollees like dual eligibles.
A downward “spiral” can result: plans that have dual eligibles receive poor ratings, which denies them bonus payments, which in turn makes them less likely to enroll more duals. Dan Rizzo, Inovalon’s CIO, stated that this negative incentive could be so strong that plans will stop offering MA altogether in some areas. For details, click here.
The study found additional characteristics of duals, discussed below.
Duals utilize equal numbers of office visits, more ambulatory visits
The study found no statistical significance on the difference in the percentage of the comparative populations receiving at least one office visit, with 94.4% of duals receiving at least one office visit compared to 94.8% of non-duals. However, the difference in ambulatory visits was statistically significant: duals received an average of 17.3 visits, while non-duals received only 13.0 visits. Ambulatory visits are outpatient visits to a hospital, which can include minor surgery, by non-resident patients of the hospital.
Duals are more medically complex
The vast majority of both duals (97%) and non-duals (close to 100%) in the data set did not have institutional status. Institutional status refers to MA beneficiaries that had spent 90 days or more in a long term care facility, such as a nursing home. Compared with less than 1% of the non-dual population, 60% of duals were in an SNP plan. Disability was a greater reason for duals’ entitlement to MA, at 35 % of the population, versus only 13% of non-duals. Age was the primary reason for non-duals’ entitlement to MA, at 87% compared to 65% of the duals population. Also, a greater percentage of duals had high (4 out of 5, or 5 out of 5) Charlson Severity Scores, as well as high CMS MA Risk Scores (1.000 and higher).
Duals are more economically vulnerable
A greater percentage of duals earned income of less than $25,000 (20 percent versus 4 percent), and 76 percent received a drug subsidy as compared to only 3% of the non-dual population.
For a link to the full study, click here.
The National Council for Medicaid Home Care – a NAHC affiliate - supports sound policy for dual eligibles in MA plans, including opposing passive enrollment for dual eligibles. For details, see page 47 of The Council’s policy blueprint, here.
Quality incentives in MA should be designed smartly to ensure that plans are not penalized for taking on additional risk in the form of more complex enrollees. The Council calls on Congress to revise the star rating system with this in mind.
Home care providers are encouraged to keep abreast of developments regarding dual eligibles on CMS’ website, and to contact the Council with any questions or concerns.