Unformatted text preview: Chapter 12 References Dunn, J.B., L. Gaines, J.C. Kelly, C. James, and K.G. Gallagher. 2015a. The significance of Li-ion batteries in
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Energy Information Administration, Office of Integrated and International Energy Analysis: 12-16 TABLE 1 3– 1 0 There was little change in results for survey-based measures in MA over the last year
Measures collected through the HOS Star rating year Improving or
physical health Improving or
mental health Monitoring
of falling Improving
control 2018 67% 85% 53% 57% 45% 2019 68 83 53 57 45 Measures collected through CAHPS® Star rating year Influenza
service Rating of
of care Rating of
coordination 2018 73% 84% 78% 90% 87% 87% 86% 2019 72 84 79 91 87 87 86 Note: MA (Medicare Advantage), HOS (Health Outcomes Survey), CAHPS® (Consumer Assessment of Healthcare Providers and Systems Survey®). Year 2018 star
ratings were released in October 2017; year 2019 star ratings were released in October 2018. Source: MedPAC analysis of CMS star data and enrollment reports. of other measures that improved is less reliable because
they are based on contract-level medical record sampling
or contract-level surveys. Those measures had incremental
improvements, including colorectal cancer screening and
eye exams for diabetics (in addition to the HOS measure
of maintaining or improving mental health), which each
improved by 5 percent. Control of blood sugar among
diabetics improved by 4 percent. Among local PPOs,
the six measures that improved were the osteoporosis
management measure (by 50 percent); the body mass
index (BMI)–recording measure (also based on medical
record sampling), colorectal cancer screening, eye exams
for diabetics, and blood sugar control among diabetics
(each by 8 percent); and the kidney disease–monitoring
measure (by 5 percent). Of the 23 star measures in 2019
that allow for HMO results to be compared with local PPO
results, results for 17 measures are within 1 percent of
each other. Local PPOs outperform HMOs in the influenza
vaccination rate (76 percent vs. 73 percent), and for five
measures, HMOs show better performance. HMOs show
substantially better performance than local PPOs in the
osteoporosis management measure (17 percent better than
local PPOs), medication reconciliation after discharge
measure (10 percent better), and managing the risk of
falling measure (7 percent better). Developing a method of comparing MA and
The need to be able to compare MA and FFS quality has
long been recognized. The Medicare Improvements for
Patients and Providers Act of 2008 includes a requirement
for the Commission to conduct a study on this issue—
that is, methods that could be used to compare MA and
FFS quality (in addition to studying how to compare
quality among MA plans). In its March 2010 report, the
Commission made a number of recommendations in
response to the mandate, including the following:
• meaningful use standards for electronic health records
should be such that those records could form the basis
of quality metrics; • quality results should be collected and reported on a
market area–basis for the two sectors; • the HOS should be fielded for FFS beneficiaries
(rather than only MA, and only if such surveys would
produce meaningful results); and • specifications for encounter data submission should
be such that encounter data could be the basis for
calculating patient outcome measures. Report to the Congress: Medicare Payment Policy | March 2019 373 Chapter 12 References Washington, D.C. Available at: . (Accessed: February
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. (Accessed: February 28, 2018). 12-17 Regarding the last point, there are many advantages
to relying primarily on encounter data as the basis for
evaluating quality in MA—not the least of which is the
ability to compare FFS and MA results using a data source
that is more likely to ensure consistency of measurement
between the two sectors. Encounter reporting is a
mechanism that is perhaps less subject to variation
across plans in MA given the standards that apply to the
submissions. Using encounter data that plans are already
required to submit can substitute for other plan reporting
and can address some of the weaknesses of the current
quality reporting system. For example, we frequently
note that plans that are new to MA tend to show poorer
performance on plan-reported quality measures collected
through HEDIS, and their ability to report improves over
time. Such improvement reflects greater familiarity with
the reporting system and better administration, but it often
does not mean there has been any change in the quality of
care. Similarly, plans with sophisticated electronic medical
record systems frequently have better HEDIS results
than other plans (compare, for example, the differences
between plans that report based on administrative data
and those that report based on medical record review for
measures in which both options are possible) (Medicare
Payment Advisory Commission 2018a). In contrast with
measures reported based on medical record sampling,
claims and encounter data (when the encounter data are
complete and accurate) can provide information on the
universe of beneficiaries receiving care. Such complete
reporting facilitates analysis of issues such as geographic
variation in quality and permits stratification by the factors
that NCQA recommends (all of which are known from
administrative data). In FFS, a number of quality measures
are already calculated using claims data (such as mortality,
readmissions, and Medicare spending per beneficiary), and
such measures could also be calculated based on encounter
Examining the Medicare Advantage star
In this section, we discuss the results of our detailed
examination of various aspects of the MA star rating
system and suggest possible ways of improving aspects of
the quality measurement system.
MA contracts are rated using a 5-star rating system that
includes up to 46 measures of clinical quality, patient
experience, and administrative performance. Measures are
assigned different weights, with outcome measures more
heavily weighted than process measures. A contract’s 374 The Medicare Advantage program: Status report star rating is the weighted average of the star values for
the individual measures. For most measures, CMS uses
what we refer to as a “tournament model” to evaluate plan
performance and to group that performance into the five
different star levels. Under this model, each year CMS
determines new statistical “cut points” for ranking plans
into the five star groups. Every year, the tournament, or
competition, among plans determines which contracts fall
into which star category—regardless of what the cut points
might have been in the preceding year.
The star rating system is intended to help beneficiaries
evaluate their Medicare choices and serves as the basis
of bonus payments to plans. Bonus payments take the
form of a 5 percent increase in the MA benchmark (or 10
percent in some counties) for plans with an overall average
rating of 4 stars or higher. In addition to the Commission’s
concerns regarding unwarranted payments and inaccurate
information on MA quality in many areas, we have
additional concerns with the implementation of the star
system. These concerns are consistent with those raised by
a technical expert panel sponsored by CMS (Damberg and
Paddock 2018) and are the subject of proposed changes in
CMS’s recent notice of proposed rulemaking (Centers for
Medicare & Medicaid Services 2018).
Contract-level reporting of quality and
nonrepresentative samples Wide contract configurations—that is, contracts extending
across a wide, disparate geographic area—have a
particular impact on quality measurement at the level
of individual star measures because of the manner in
which the measures are collected and reported. Of the 11
HEDIS clinical quality measures in the star system that
plans report for all enrollees, 7 are based on a sample of
medical records (with only a few plans reporting based
on administrative data for 6 of the 7 measures). These
measures constitute 65 percent of the weight of the HEDIS
non-survey-based measures. Under current rules, it is
sufficient for a contract to use a sample of 411 medical
records to report on the 7 HEDIS measures (to obtain a
sample result with a 95 percent confidence level). For
measurement year 2016, the largest MA contract (with
over 1 million enrollees) used a sample of 437 diabetics
to determine the contract-level rate of blood sugar control
among diabetics; 25 percent of the contract’s enrollment
was in states with 5 or fewer enrollees in the sample
of 437, and 4 percent of the contract’s enrollment was
in states not represented at all in the sample. Given the
extent to which the quality of medical care can vary from ...
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