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Medicare Advantage rankings hit plans serving disadvantaged populations hard

After adjustments for race, poverty level, other factors, plans serving the highest proportions of disadvantaged populations improved considerably.

Jeff Lagasse, Associate Editor

Federal rankings of Medicare Advantage plans may unfairly penalize those who enroll a disproportionate number of non-white, poor and rural Americans, according to new research from Brown University.

The study, published in Health Affairs, used data collected by the Centers for Medicare and Medicaid Services to measure the quality of care provided in Medicare Advantage plans, and adjusted performance rankings for race, neighborhood poverty level and other social risk factors. After the adjustments, plans serving the highest proportions of disadvantaged populations improved considerably in the rankings.

The findings show that existing Medicare Advantage plan rankings may not accurately reflect the quality of care received by enrollees of a given plan, the authors said. Policymakers have focused on measuring quality and rewarding better performance among providers and health plans, but they typically don't account for the characteristics of the populations in question.

Medicare Advantage is a newly popular option among Americans who qualify for Medicare. Before the 21st Century, almost everyone opted for traditional Medicare, which allowed beneficiaries to visit any medical professional they wanted. 

But today, almost a third of those who qualify for Medicare choose the more affordable Medicare Advantage. While patients who use Medicare Advantage are restricted to specific networks of doctors, they're also able to compare dozens of plans based on rankings, cost and other factors.

For the last decade, the authors said, CMS rankings have measured a plan's quality by examining how well its providers perform in about 30 categories, including customer service, efficiency in processing claims and appeals, disease screening rates and patients' body mass indexes.

When the Brown researchers adjusted for socioeconomic disadvantage in just three of those categories -- blood pressure control, cholesterol control and diabetes control -- they found that many lower-ranked plans suddenly moved substantially higher in the rankings.

The team chose to adjust the data in those three categories because previous literature had shown that disadvantaged populations disproportionately suffer from uncontrolled high blood pressure, high cholesterol levels and diabetes.

Currently, CMS rankings account for just two risk factors: dual eligibility -- which indicates that someone qualifies for both Medicare and Medicaid -- and disability.

Accurate quality rankings are important because CMS gives plans an incentive to compete against each other. A plan that receives a five-star rating is rewarded with a sizeable payment bump. A plan that gets a one-star rating, on the other hand, is penalized -- and all of its enrollees receive letters encouraging them to switch to better plans.

The researchers said that if plans notice a connection between their low rankings and their socioeconomically disadvantaged enrollees, they'll have little incentive to continue serving the underserved.

While it's still unclear what precise set of adjustments will lead to the most equitable CMS rankings, the authors said they hope the agency soon takes action one way or another. 

One thing is clear from the study. Determining whether and how to adjust Medicare Advantage plan quality measures for sociodemographic factors is critically important to accuracy and equitable payment.

Twitter: @JELagasse
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