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12-12 be complete (for example, we do not have good data on
MA plans’ use of post-acute care); it is not possible to
compare measures that MA collects by means of medical
record sampling with FFS results unless there is a similar
data collection process; and for measures that would have
to be risk adjusted (such as mortality rates), differences
in MA and FFS coding practices need to be taken into
account. The wave of contract consolidations has reduced
the ability to have valid comparisons among MA plans,
particularly for measures based on medical record
sampling. As contracts cover larger and larger geographic
areas, contract-level samples of 411 records cannot be
relied on to examine differences among MA plans because
those samples represent different geographic areas and are
not otherwise representative of the population served by a
plan in a given area. With the current state of MA quality
data, reliable information comparing FFS and MA, or
comparing different MA plans in an area, is not available
to an important audience—Medicare beneficiaries—as we
show with an illustrative example (p. 370).
The Commission’s March 2018 report to the Congress
contains a detailed discussion of the difficulty of
evaluating the quality of care within the MA sector and
changes in MA quality from one year to the next. The
current rating system uses a 5-star scale to determine
performance at the level of individual quality measures
(such as clinical quality measures and patient experience
measures) and then determines an overall star rating
that is the weighted average of up to 46 measure-level
star ratings. The overall star rating is the basis for bonus
payments in the MA quality bonus program, with bonuses
available when the overall star rating is 4 stars or higher.
What has made this system unreliable as a basis for
evaluating quality is that collection and reporting of each
of the 46 measure results, and the determination of the
overall star rating, occurs at the level of the MA contract.
Under current rules, an MA contract can include any
number of geographic areas, and there is no requirement
that the areas be contiguous. In 2018, about 40 percent
of MA enrollees were in HMO or local PPO contracts
that drew a substantial number of enrollees from contract
service areas consisting of noncontiguous states. The
largest MA contract, with 1.3 million enrollees as of July
2018, had over 1,000 enrollees in each of 45 states and
over 20,000 enrollees in each of 18 states. The top five
states in enrollment for this contract had 47 percent of the
plan’s enrollment: Alabama, California, Georgia, Illinois,
and North Carolina. In 2010, given how much the quality of care can
vary from one local area to another, the Commission
recommended that CMS change to reporting at the local
market area level (suggesting the use of metropolitan
statistical areas and, in nonmetropolitan areas, groupings
based on the patterns of where beneficiaries received
care). This recommendation was repeated in our March
2018 report to the Congress. The Commission’s repeating
of the 2010 recommendation was prompted by another
issue that the Commission has examined extensively,
which is the practice of consolidating contracts to achieve
higher star ratings. CMS has encouraged sponsors to
consolidate their MA contracts to streamline program
administration for CMS and for plan sponsors. Through
2019, the rules for determining star ratings, and therefore
eligibility for bonus payments, provided plan sponsors
with the opportunity to use the contract consolidation
strategy to obtain unwarranted bonus payments. A
sponsor is permitted to consolidate two or more contracts
and choose which contract would be the “surviving”
contract. The star rating of the surviving contract applies
to the “consumed” contract(s) immediately—both for
purposes of bonus payments and the star rating appearing
on the Medicare Plan Finder site that beneficiaries can
use to choose among plans. For 2019, plan sponsors
have used this strategy to move about 550,000 enrollees
from nonbonus contracts to bonus-level contracts,
resulting in unwarranted bonus payments in the range of
$200 million in 2019. In the preceding five years, over
4 million enrollees were moved from nonbonus plans
to bonus plans, including situations in which surviving
contracts that fell below 4 stars underwent subsequent
consolidations and were consumed by bonus-level
Effective 2020, the Bipartisan Budget Act of 2018 changes
the policy on plan consolidations. For new consolidations,
the star rating of the surviving contract will be the
enrollment-weighted average of the quality results for
the contracts being merged. While this change in policy
will prevent sponsors from obtaining unwarranted bonus
payments when a small, highly rated contract absorbs a
larger nonbonus contract, sponsors will still be able to
obtain unwarranted bonus payments by consolidating
contracts when they can be assured that the weighted
average results from combining nonbonus and bonus-level
contracts will produce a bonus-level star rating for the
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. (Accessed: June 21, 2018). 12-13 TABLE 13–8 In 2017, fee-for-service and Medicare Advantage Consumer Assessment
of Health Providers and Systems® performance rates were simlar CAHPS measure FFS MA Getting needed care and seeing specialists 84% 84% Getting appointments and care quickly 77 78 Care coordination 86 86 Rating of health plan 83 86 Rating of health care quality 85 86 Annual influenza vaccine 74 73 Note: CAHPS® (Consumer Assessment of Healthcare Providers and Systems®), FFS (fee-for-service), MA (Medicare Advantage). The MA rate is the enrollment-weighted
average rate for all MA contract types other than cost-reimbursed HMOs. Other than the influenza vaccination rate, rates are case-mix adjusted for response bias.
Source: MA CAHPS based on MedPAC analysis of 2018 plan ratings. FFS CAHPS mean scores provided by CMS. Comparing MA and FFS quality
As we have noted, currently, there is only one source
of data provided to beneficiaries through the Medicare.
gov website that can be used for a direct comparison of
MA and FFS, which is the patient experience measures
and the influenza vaccination rates collected through
the Consumer Assessment of Healthcare Providers and
Systems® (CAHPS®). At a national average level, in 2018,
there was little difference between MA and FFS results,
though the influenza vaccination rate is lower among MA
enrollees in HMOs as compared with the national average
FFS rate (Table 13-8). The 2018 results are similar to past
years’ results (see, for example, the 2015 results in the
Commission’s March 2017 report to the Congress, where
the only meaningful differences were in the influenza
vaccination rates, with HMOs and FFS at about the same
level (72 percent) and local PPOs at 74 percent (Medicare
Payment Advisory Commission 2017).
There may be some value in having information about a
national-level comparison of MA and FFS performance,
but of greater importance to beneficiaries—and, arguably,
to policymakers— is to have market-level comparisons.
While the Medicare Plan Finder website provides
beneficiaries with the CAHPS information by MA contract
and for FFS by geographic area, a specific example we
discuss below illustrates the issues with the current method
of collecting and reporting data as it affects comparisons
of MA plans and an MA-to-FFS comparisons. The issues
are common to both the CAHPS data and the other quality
measures that plans report. 370 The Medicare Advantage program: Status report In our illustrative example, a beneficiary residing in
Phoenix, AZ, is looking to enroll in an MA plan in 2019
and wishes to compare MA results with FFS results. For
the influenza vaccination rate reported through CAHPS,
the FFS rate is a statewide rate for all of Arizona (74
percent). For the MA plans available in Phoenix in the
Plan Finder results for the 2019 enrollment period,
reported influenza vaccination rates range from 55
percent to 79 percent. However, the contract with the 79
percent rate had no enrollees in Arizona at the time the
vaccination rates were determined. The 79 percent rate
is based on enrollment in a contract that drew one-third
of its enrollment from Hawaii, nearly half from Iowa,
and nearly 20 percent from Nebraska. This contract
is present in the Phoenix market in 2019 as a result of
a contract consolidation whereby this sponsor’s 2018
Arizona contract (with a star rating below bonus status)
was absorbed by the Hawaii-Iowa-Nebraska contract (with
a bonus-level star rating), thereby enabling the sponsor’s
Arizona enrollees to be in a contract with a bonus-level
star rating for 2019 payments. The Arizona contract
absorbed by the Hawaii-Iowa-Nebraska contract was
itself the product of a consolidation into a contract that
originally served the contiguous states of Missouri and
Kansas and then absorbed five single-state contracts in
Colorado, Illinois, New Mexico, and Texas, in addition to
an Arizona contract.
A within-Arizona comparison of MA and FFS results on
the influenza vaccination measure is possible because
there are MA contracts in Arizona that in 2018 only ...
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