Is it Time to Revamp the CMS Star Rating System?
Healthcare providers are looking to change the CMS star rating to better account for the dual eligible population.
- The Centers for Medicare and Medicaid Services (CMS) 5-Star quality rating system measures how well Medicare Advantage and prescription drug (Part D) plans perform. In scores several categories, including quality of care and customer service. Than a range of one to five stars is assigned for total services and each individual category. This allows consumers to find the best possible care for them by comparing ratings, which are updated every year. These ratings are something that those with four or five stars tout highly.
However, not every provider is happy with how the rating systems works. According to a recent report from WUSF, a news outlet in Tampa Bay, Florida, Tampa-based WellCare Health Plans is leading a push to get the scale realigned. It’s plans are rated at either a three or three-and-a-half stars, which is below the minimum requirements to qualify for bonus payments. However, the rating could be inaccurate because it “unfairly penalizes plans focused on serving low-income, medically complex members.”
WellCare released a white paper that outlines its argument. The biggest factor is the unique characteristics of the Medicare/Medicaid dual eligible population. Duals, as the report refers to them, tend to be sicker, poorer, less educated, have lower health literacy, be members of a racial/ethnic minority population, and have more housing and income instability than non-Dual Medicare beneficiaries.
The Medicare star quality rating system measures the average of Medicare beneficiary’s experience, not that of members with health, education and economic characteristics of being dual eligible. Instead, it should be modified to more accurately measure this unique population. In the short term this means applying weighting factors to more appropriately reflect the needs of dual eligibles and in the long term means creating new measures for this population.
“The health status of Medicare beneficiaries at the point of health plan enrollment impacts stars scores,” the white paper reads. “Stars measures rate health status, access to care, care coordination and patient satisfaction for Medicare beneficiaries over a two-year period, but the measures do not adequately account for the existing health and mental status of an individual upon enrollment. Because duals enter the survey sample in poorer health compared to non-Duals, there is an inherent disadvantage for the plans that serve them.”
This is something that CMS is already paying attention to. Earlier this year, the organization asked WellCare for any information related to revenue disparities that are related to the rating methodology. It also funded a study by the National Quality Forum that focuses on improving the quality of healthcare.
While the five star rating system has become an industry standard, it could be in need of tweaking. Any rating system worth paying attention to is able to be adjusted with a changing environment and it seems like the CMS rating system could be ready for a little overhaul.
