JustCare

Tag: Ratings

  • Don’t assume a five-star Medicare Advantage plan will provide the care you need

    Don’t assume a five-star Medicare Advantage plan will provide the care you need

    Laura Beerman writes for Health Leaders on the flaws in the Medicare Advantage star-rating system. If you asked me, I’d tell you it’s a farce. The gaming that goes on to get four and five-star ratings is unacceptable. And, even with a five-star rating, the Medicare Advantage plan may be engaged in widespread and persistent delays and denials of care. Don’t assume a five-star Medicare Advantage plan will provide you with the care you need.

    You can’t know whether a particular Medicare Advantage plan will endanger your health if you need costly and complex care, in part because the government hides information about plans engaged in bad acts. While you should avoid Medicare Advantage plans that do not have four or five-star ratings, you are taking a huge gamble even if you sign up with Medicare Advantage plans that have four and five-star ratings. These ratings do not reflect whether you will be covered for care from top flight doctors and hospitals or how much hassle you will face getting the care you need. And, that’s what you should care about when choosing a Medicare Advantage plan.

    The health insurers offering Medicare Advantage tend to love the star-rating program. If they can get the stars, they earn huge additional revenue from the government. And, believe it or not, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare Advantage, allows the insurers to bundle together several Medicare Advantage plans when applying for star-ratings. So, if one Medicare Advantage plan performs poorly based on the measures CMS uses to give stars, it can still “look” good in terms of the number of stars it has.

    If you don’t believe me, just read this piece by two former leaders at CMS: The Emperor Has No Clothes: “[T]he Five-Star program, while well intended, primarily creates a ‘performing to the test’ result rather than solid and important quality improvements in outcomes.”

    In fairness, CMS has gotten a bit tougher in its standards for doling out five and four-star ratings to Medicare Advantage and Part D prescription drug plans. But, not nearly tough enough. Nor has CMS created standards that would actually reflect whether a Medicare Advantage or Part D plan is engaged in massive inappropriate delays and denials of care and coverage or does a good job of managing your care. More than half of all Medicare Advantage plans in 2023 had a four or five-star rating!

    Alignment Health, Elevance Health, Humana, and UnitedHealthGroup all received four or five-stars for their Medicare Advantage plans, as did Kaiser Permanente. Again, don’t assume much positive about these plans when it comes to whether they are covering their enrollees’ care as required under their contracts.

    Aetna Medicare Advantage plans fared worse than others with only 21 percent of its Medicare Advantage plans receiving four or five-star ratings. Should you avoid Aetna Medicare Advantage plans with three-star ratings? It’s not clear, but probably. They are being paid as much as $1 billion less in 2024 because of the lost stars, which means they will have less money to spend on your care.

    MedPAC, the independent agency that oversees Medicare Advantage quality, has said several times in its annual report to Congress: “[T]he Commission has been increasingly concerned that Medicare’s approach to quality measurement is flawed because it relies on too many clinical process measures.” In 2023: “Over the years, the Commission has determined that the QBP [Quality Bonus Program] is flawed and does not provide a reliable basis for evaluating quality across MA plans in meaningful ways…”

    Here’s more from Just Care:

  • What happens when Medicare Advantage overpayments end?

    What happens when Medicare Advantage overpayments end?

    Tens of billions of dollars a year in Medicare Advantage overpayments are taking a huge toll on the Medicare Trust Fund and driving up Medicare Part B premiums. They also are not deterring Medicare Advantage plans from inappropriately delaying and denying care and coverage. So, what happens when the administration or Congress ends these overpayments?

    Becker’s Payer Issues reports that Aetna Medicare Advantage plans are losing as much as $2 billion in 2024, in part because many fewer of them will receive a four-star rating or better. As it is, the stars are a joke and do not reflect, for example, whether a Medicare Advantage plan engages in widespread inappropriate delays and denials of care. But, a four or five-star rating means real money to the Medicare Advantage plans. Without that money, these Medicare Advantage plans might look for other ways to maximize profits. Will inappropriate delays and denials increase? Will the quality of the provider networks suffer?

    CVS Health owns Aetna. It is losing money because of the reduction in number of its four and five-star Medicare Advantage plans. It is also losing money because of a contract it lost with Centene, a Medicare Advantage plan. CVS Health has been providing pharmacy benefits to Centene Medicare Advantage members.

    Here, you should take note: If you are in a Medicare Advantage plan and get prescription drug coverage, don’t assume you are getting the lowest price. Always check for other ways to get your drugs that could possibly save you more money, such as through Costco mail-order or CostPlus Pharmacy. The full cost of the drug without insurance could be less than your Medicare Part D copay.

    CVS Health continues to invest heavily in getting more Medicare Advantage enrollees. The flawed Medicare payment system pays their Medicare Advantage plans more when their enrollees have more diagnosis codes, even when they do not cost their Medicare Advantage plans more to treat.

    Today, CVS Health has 3.4 million Medicare Advantage members. And, it expects a 12 percent increase next year. UnitedHealth and Humana are the two insurers with the highest Medicare Advantage enrollment.

    CVS Health recently purchased Oak Street Health, a primary care provider group, which will help ensure that they have more control over the diagnosis codes providers give to their patients. CVS Health also says it will enable them to improve their star ratings.

    [This post has been edited to correct a factual error regarding the relationship between Centene and CVS Health.]

    Here’s more from Just Care:

  • 2023 Medicare Advantage star ratings fall

    2023 Medicare Advantage star ratings fall

    Medicare Advantage plan star ratings have always been a farce, and you should not trust them. Most Medicare Advantage plans have four or five stars, and they still might offer poor quality care. Because of a change in the way the government weights different metrics, Medicare Advantage star ratings are falling a bit, reports Axios.

    In 2023, 57 health insurers will offer Medicare Advantage plans with five-star ratings. This year, 74 health insurers offer Medicare Advantage plans with five-star ratings. The ratings are supposed to be based on quality measures, including consumer assessments, but the question is what goes into those measures and how are they weighted.

    The government looks at how well the Medicare Advantage plans do at customer service, as well as keeping members healthy through preventive services and management of chronic conditions. The government also looks at member complaints. The Centers for Medicare and Medicaid Services (CMS) audits the data the Medicare Advantage plans report. But, Medicare Advantage plans can game the system to achieve higher ratings.

    In fact, the federal government has never been able to assess the quality of care Medicare Advantage plans offer, overall, let alone individually. The Medicare Payment Advisory Commission (MedPac) repeatedly has said in its reports on Medicare Advantage that the health plans fail to disclose complete and accurate data, as required by law, to enable proper assessment of plan quality. Four and five-star rated Medicare Advantage plans could deliver poor health outcomes or otherwise jeopardize patient care, which might not be captured in the data CMS collects.

    For sure, there is star-rating inflation. The average rating for all Medicare Advantage plans is more than four stars, 4.15 out of 5 stars. That’s down from 4.37 stars in 2022. Some plans, such as those offered by CVS Health and Centene, saw a big drop in star ratings and are now restricted in their ability to grow their enrollment. But, it does not appear that the the government notifies people already enrolled in those plans, let alone suggests they disenroll from them.

    During the upcoming open enrollment season, if you opt for Medicare Advantage over traditional Medicare, don’t choose a Medicare Advantage plan by its stars or by the extra benefits they offer (which often are not what they appear to be.) Talk to your doctors and friends in the health plans you are considering, particularly people who have needed a lot of costly care. Find out whether they believe they have gotten the care they needed, without undue delays, and what they had to pay out of pocket.

    During the pandemic, star ratings were weighted less heavily towards consumer satisfaction. Now, CMS is relying more heavily on patient survey data for its ratings, which is affecting ratings for some plans.

    While consumer data only captures one aspect of quality, all Medicare Advantage plans are different in multiple ways. People in some plans face higher rates of delays and denials of care than in other plans. Several expert studies also show that many Medicare Advantage plans have disproportionate rates of disenrollment by people with costly and complex conditions.

    Medicare Advantage plans with lower star-ratings get less money from the government for their services, which could affect the benefits they offer and shift more costs onto their enrollees.

    Here’s more from Just Care:

  • Most Medicare Advantage plans will see lower star-ratings

    Most Medicare Advantage plans will see lower star-ratings

    Robert King writes for Fierce Healthcare about a change to Medicare’s star-rating system for Medicare Advantage plans. As a result of Medicare’s change to its star-rating system, a new analysis finds that the overwhelming majority of Medicare Advantage plans will face lower star-ratings.

    For some time now, the federal government has tried–unsuccessfully–to help people distinguish among Medicare Advantage plans–corporate health insurance plans that are paid to cover Medicare benefits. Medicare Advantage plans are an alternative to traditional Medicare, which is public health insurance that covers your care from most doctors and hospitals across the US and is administered directly by the federal government.

    The government uses a “star-rating” system to help people distinguish among Medicare Advantage plans. But, the stars the government gives Medicare Advantage plans are no way to gauge whether a Medicare Advantage plan will cover your care from physicians you trust when you need it.  From the perspective of people with Medicare, the stars are a farce because the Medicare Advantage plans have been able to game them and they do not measure key differentials among Medicare Advantage plans. For example, the star-rating system does not factor mortality rates in different Medicare Advantage plans and rates of inappropriate delays and denials of care.

    The Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare, is now raising the bar for getting stars in 2023.  It will be giving double the weight it has to customer service, accessing prescription drugs, care coordination and health care quality.

    Under this new way of calculating star-ratings, nearly 50 percent of Medicare Advantage plans would lose one star. The loss of a star speaks to the difficulty that enrollees are increasingly facing getting prescription drugs in their Medicare Advantage plans. More Medicare Advantage enrollees are unsatisfied with their ability to fill their prescriptions at a reasonable out-of-pocket cost.

    From the Medicare Advantage plans’ perspective, losing a star or two means loss of significant revenues, often millions and sometimes billions of dollars. Without that money, Medicare Advantage plans might not be willing to offer as generous benefits. It will also be harder for them to retain enrollees.

    More than four in ten (44 percent) Medicare Advantage plans could lose a star because their enrollees are less satisfied with customer service and care coordination.

    Press Ganey performed the analysis in early 2022, based on data from 446 Medicare Advantage plans.

    Since 2015, Medicare Advantage plan quality bonuses have nearly quadrupled, from $3 billion to $11.6 billion. Part of the increase is attributable to the government awarding bonuses to more Medicare Advantage plans. Part of the increase is attributable to the number of enrollees in the Medicare Advantage plans that received bonuses.

    Here’s more from Just Care

  • Medicare hospital star-ratings are a farce

    Medicare hospital star-ratings are a farce

    Every year, Medicare penalizes hospitals that underperform. This year, it penalized 764 hospitals because they had high rates of patient infections and complications that could have been avoided. Jordan Rau of Kaiser Health News reports that, of those it penalized, it gives five star-ratings to 38, signaling that they are among the best in the nation.

    Medicare penalized an additional 138 hospitals with four-star ratings. Do not rely on these star-ratings exclusively when choosing a hospital!!!!

    Medicare penalizes hospitals financially with a one percent reduction in payments if Medicare patients experienced high readmission rates, death rates, infection rates, and/or said they had a poor experience. The goal is to get hospitals to minimize bedsores, hip fractures, infections and blood clots.

    Many hospitals that you might think of as first-rate were penalized this year, including the Cleveland Clinic in Ohio, the Mayo Clinic in Red Wing, Minnesota and Phoenix, Arizona. Each of these hospitals had Medicare five-star ratings.

    It’s not at all clear that the penalties are changing hospital practices, based on recent analyses. It’s also not clear that all hospitals are reporting accurate information that would result in assessing penalties against them. The penalties are a big financial hit for hospitals.

    The penalties might save Medicare money, but they seem poorly designed. They must be charged to the 25 percent of hospitals with the greatest safety issues, even if these hospitals perform about the same as other hospitals or they have improved significantly from the prior year.

    Medicare cannot impose a penalty on critical care access hospitals. They tend to be rural hospitals. They can also be rehab, psychiatric and long-term care hospitals. Hospitals in Maryland are also excluded because they are paid under an all-payer system.

    Of note, Medicare does not penalize Medicare Advantage plans that perform poorly in the same way. It is not required to reduce payments to the worst performing MA plans. In fact, it doesn’t even recoup tens of billions of dollars in overpayments to them, driving up costs for everyone with Medicare and eroding the Medicare Trust Fund.

    Here’s more from Just Care:

  • Don’t judge a Medicare Advantage plan by its stars

    Don’t judge a Medicare Advantage plan by its stars

    When you examine your Medicare plan options during this year’s open enrollment season, do not judge a Medicare Advantage plan by its stars. The government’s star-rating system is deeply flawed. Rather, you should assume that some plans with four and five-star ratings have high denial and mortality rates and low-quality provider networks.

    For sure, you should avoid Medicare Advantage plans with one and two-star ratings. They are few and far between. And, if the Centers for Medicare and Medicaid Services is giving them such a low rating, there’s a reason.

    But, the higher star-ratings are based on measures that can be extremely misleading. For one, the star ratings are determined on an insurer’s group of Medicare Advantage plans, at the Medicare Advantage “contract level.” If there’s a Medicare Advantage plan that’s performing poorly that is assessed with others that are performing better, that poor-performing Medicare Advantage plan will reap the star-rating of its fellow plans. And, people who join that poor-performing plan will have no clue.

    MedPac has proposed changing the star-rating program, which it says is “flawed.” It is “inconsistent with the [MedPac] Commission’s principles for quality measurement.” In addition to giving plans ratings based at the “contract level” and not the individual plan level, the Centers for Medicare and Medicaid Services (CMS) does not focus on population-based outcome and patient experience measures. In addition, plans are rated as compared with one another, not relative to objective performance targets. And, plans are not rated by subpopulations served, so there’s no way to know if a plan with a high rating is actually meeting the needs of its members with special needs and costly conditions.

    Another issue with the star-rating system is that it is not budget neutral. The more plans with four- and five-star ratings, the higher their payments. This means that Medicare Advantage plans are not operating on a level playing field with traditional Medicare.

    How should you choose a Medicare plan? If you want easy access to care from your choice of doctors anywhere in the US and few if any out-of-pocket costs, traditional Medicare is your best option. But, you will need supplemental coverage—Medigap, retiree coverage or Medicaid—to protect yourself financially. To choose a Medicare Advantage plan, talk to your doctor. Pick a plan that has the doctors you want to see and hospital you want to use in its network. And, keep in mind that if you need costly health care services, your out-of-pocket costs could easily be $5,000 for in-network care alone.

    Fierce Healthcare reports that, in 2022, almost seven in ten Medicare Advantage plans have a four-star or five-star rating. That’s up from not even five in ten in 2021.

    Here’s more from Just Care:

  • Don’t trust Medicare nursing home star ratings

    Don’t trust Medicare nursing home star ratings

    Two and a half years ago, I warned people not to be misled by Medicare five-star nursing home ratings. Unfortunately, you still can’t trust these nursing home star ratings. If Medicare can’t ensure that all nursing homes deliver high quality care, at the very least it needs to rate them appropriately.

    The New York Times reports that the nursing home gaming of Medicare star ratings continues. The star-rating system is broken. More than two-thirds of the 3,500 nursing homes with five-star ratings have been cited for problems with infection control and patient abuse.

    Five-star nursing home ratings continue to be misleading. Of the 130,000 nursing home residents who have died of COVID-19, those in five-star nursing homes were as likely to die as those in one-star nursing homes. Five-star nursing homes often fail in-person inspections.

    The New York Times reports that California is suing Brookdale Senior Living, the nation’s largest nursing home chain, for filing false information about its services to Medicare, with the goal of getting a high star-rating. Part of the problem is that Medicare relies mostly on unaudited and self-reported data to determine the number of stars it gives a nursing home.

    Naturally, nursing homes have an incentive to game the system. A five-star rating can lure more people to them and boost profits. Brookdale is alleged to have cooked its payroll books so that CMS would see high staffing levels at its nursing homes, Brookdale also allegedly asked its staff to misrepresent the amount of care their patients receive.

    Here’s more from Just Care:

  • 2020: Comparing your Medicare private options

    2020: Comparing your Medicare private options

    As you’re thinking about your Medicare options this Fall, don’t be seduced by the bells and whistles available from some Medicare Advantage plans, the Medicare private options through which corporate health insurers contract with the federal government to deliver Medicare benefits. These corporate health plans profit from denying their members needed health care, and many of them deny care all too often. The big problem is that it is impossible to know which ones do and which ones do not. 

    Congress allows Medicare Advantage plans to spend money on health-related services that otherwise would be spent on medical services. Those might be valuable. But, the question is to what extent these health plans are stinting on the delivery of medical care, which could be more critical to your health and well-being if you have or develop a complex condition. And, that is hard to know. 

    The corporate Medicare plans do not explain how they allocate funds for the additional non-medical services they offer. They are not receiving extra money to do so. For the last several years, federal audits suggest that they have overcharged the government tens of billions a year for their services. Those overpayments may be one way they fund the non-medical services they sometimes offer, though the government is trying to get that money back.

    They also may be funding these extra services by denying coverage for critical medical care inappropriately and/or by charging high copays for people who need care. There is no data on plan denial rates or copay amounts these plans charge their members for different services, so neither denial rates nor copay amounts can be a basis for choosing a plan.

    Medicare private health insurance options also are not reporting accurately or completely the Medicare-covered services they are delivering their members, as they are required to do by law. That should give people who consider joining these plans pause. It’s reasonable to believe that they are stinting on the delivery of the medically necessary services they are supposed to be covering and charging high copays for costly services.

    Given the data, you should be concerned that if you join a Medicare private plan, you might be denied the care or coverage your treating physicians believe you need. Unfortunately, the star-ratings are of no help in choosing a plan.

    All this said, Medicare Advantage plans have lower upfront costs than traditional Medicare. Because traditional Medicare does not have an out-of-pocket cap, it can be expensive to buy supplemental coverage that fills gaps, if you don’t have wrap around coverage from a former employer or Medicaid. And, if you end up not needing a lot of care, it can be more expensive than Medicare private health insurance.

    The problem is that if you have a complex condition, you are taking a gamble with Medicare private options. You’re gambling that the doctors you want to use are in the network and remain in the network. You are gambling that it will cover the care you and your doctors believe you need. You’re gambling that the copays will not be prohibitive and create a barrier to care. Your out-of-pocket costs for in-network medical care alone can be as high as $7,550 a year.

    Do a lot of homework before choosing a Medicare private plan. Talk to your doctors. Find out which Medicare Advantage plan networks they are in, which Medicare Advantage plan they like most, and which, if any, they have issues with. You can get free guidance from your State Health Insurance Assistance Program or SHIP.

    One thing to keep in mind. If you are switching from fee-for-service traditional Medicare, (the Medicare public option,) to a Medicare Advantage plan, you might not be able to switch back. You could be locked out of traditional Medicare if you develop a health condition and live in a state that does not require Medicare supplemental insurers to sell you coverage that fills gaps in Medicare. Only four states require insurers to sell coverage, New York, Connecticut, Massachusetts and Maine.

    Here’s more from Just Care:

  • Traditional Medicare offers better home care benefits than Medicare Advantage

    Traditional Medicare offers better home care benefits than Medicare Advantage

    If you have Medicaid or can afford supplemental coverage to fill gaps in traditional Medicare, here’s another reason to think twice before signing up for a Medicare Advantage plan. Researchers at Brown University’s School of Public Health have found that Medicare Advantage plans do not offer the high quality home health care benefits that traditional Medicare offers. Traditional Medicare home health care services are better, they report in JAMA Network.

    People in traditional Medicare, overall, have access to far higher quality providers than people in Medicare Advantage plans. Last year, researchers at Brown University found that traditional Medicare offers higher quality skilled nursing facility benefits than Medicare Advantage plans. Medicare Advantage plans contract with poorer quality providers.

    Of course, people in good health need not be too concerned about the quality of care their health insurance offers them. But, all of us can be hit by a car, or slip and fall, or otherwise develop a costly condition at any time. So, it’s important to pick a Medicare plan that will meet your needs in the long-term.

    Unfortunately, data about the quality of care in particular Medicare Advantage plans is not available. But, the Brown University researchers found that people with costly health conditions were more likely to leave their Medicare Advantage plans and enroll in traditional Medicare. That’s another sign that Medicare Advantage plans are not meeting people’s needs when they need costly care.

    For their home health care study, the researchers analyzed data from 4.4 million people who received home health care. They could not independently assess the quality of the home health agencies serving people in Medicare Advantage plans. Instead, they determined quality based on star ratings, which can be seriously flawed. They found a “significantly” greater likelihood of getting high-quality care in traditional Medicare than in Medicare Advantage. Consequently, people in Medicare Advantage plans may suffer negative health outcomes.

    The researchers posit that Medicare Advantage plans save money by contracting with lower quality home health care agencies, just as they save money by contracting with lower quality skilled nursing facilities. Unfortunately, the Centers for Medicare and Medicaid Services does not factor in the quality of home health care agencies in a plan’s network when determining a Medicare Advantage plan’s star rating.

    The Kaiser Family Foundation has also looked at the quality of providers in Medicare Advantage plans and found that people in these plans are less likely to be able to use centers of excellence when they have cancer.

    Here’s more from Just Care:

  • Senators ask Medicare agency why it is not holding Medicare Advantage plans accountable for violating their contractual obligations

    Senators ask Medicare agency why it is not holding Medicare Advantage plans accountable for violating their contractual obligations

    On September 13, 2019, six Democratic Senators sent a letter to Center for Medicare and Medicaid Services (CMS) Administrator, Seema Verma, detailing their concerns about the well-being of people enrolled in Medicare Advantage plans and the integrity of the Medicare Advantage program. The Senators ask CMS why it is not holding Medicare Advantage plans accountable for violating their contractual obligations; rather, Medicare Advantage plans are jeopardizing the health and safety of their members and overbilling taxpayers to the tune of around $10 billion a year.

    The letter, signed by Senators Sherrod Brown, Debbie Stabenow, Chris Murphy, David Blumenthal, Amy Klobuchar and Bernie Sanders, urges prompt action of Administrator Verma to ensure that Medicare Advantage plans are held accountable for meeting their contractual obligations and managing the health care needs of their members. The Senators want to ensure that deficiencies in oversight of Medicare Advantage plans are addressed. The Senators pose 19 questions to Verma on six areas of concern.

    Recouping and preventing Medicare Advantage plan overpayments: Government audits show tens of billions of dollars in overpayments to MA plans and an inability of CMS to recoup this money. Four questions focus on the need for Congress to ensure the financial integrity of the Medicare Advantage program and protect the US Treasury. CMS needs to explain whether and how it plans to recoup overpayments from MA plans. If it can’t recoup this money, CMS needs to explain its plans to ensure it does not continue to overpay them. The Senators ask whether CMS has the tools to hold the Medicare Advantage plans accountable.

    Ensuring network adequacy and accurate provider directories: Government audits reveal that provider directories are often inaccurate, and it is not evident that CMS is ensuring network adequacy. Three questions go to why Medicare Advantage plans are not publishing accurate provider directories as required by law and what’s keeping CMS from ensuring there are enough health care providers in the plan’s network.

    Securing encounter data, which show the health care services MA plan members receive: Government audits reveal that Medicare Advantage plans are not providing CMS with complete and accurate encounter data as required by law. Two questions ask how CMS is going to secure, report and ensure the accuracy of Medicare Advantage plan encounter data. The Senators support MedPAC’s recommendation that CMS reduce payments to Medicare Advantage plans that do not provide complete and accurate data.

    Holding Medicare Advantage plans accountable for persistent performance problems: Government audits show that Medicare Advantage plans may be inappropriately delaying and denying care and coverage to their members. Five questions concern how CMS enforces MA plan standards and protects enrollees, particularly when their health and safety are at risk, as well as whether CMS needs additional resources. The Senators ask CMS to report those Medicare Advantage plans with performance problems and the nature of those problems on the Medicare Plan Finder.

    Ensuring star-ratings are not misleading: Medicare Advantage plans found to threaten members’ health and safety can receive four and five-star ratings. The Senators ask what CMS is doing to address these misleading star-ratings.

    Ensuring informed health plan choices: CMS has not provided people with Medicare information on plans with high denial rates and plans that have been found to threaten people’s health and safety. It does not disclose that people who forego traditional Medicare when they first enroll may not be able to switch later, since plans that fill gaps in coverage may not be available to them. It does not mention that people enrolled in Medicare Advantage plans could be liable for as much as $6,700 out of pocket for in-network care alone. And, CMS has steered people into Medicare Advantage plans with misleading information.

    Here’s more from Just Care: