CMS Quality Measurements for Medicare Advantage, the Red Herrings of healthcare

Quality metrics built into the regulations by CMS have become the norm.  These measurements are set to improve or be a proxy quality healthcare.  Measuring outcomes is designed to modify the behavior of health plans, hospitals and physicians to adopt quality in their organizations.  It is highly unlikely that any of these entities are purposely practicing bad medicine.  The question is whether the measurement centric CMS rules are accomplishing the goals or quality improvement or just red herrings?  The better way of achieving this result is for the adoption of Population Healthcare processes at the primary care level.

To level set, it is important to define Population Healthcare.  Population Healthcare is the active management of all the patient/members chronic diseases.  Population Healthcare involves primary care physicians (PCP) diagnosing, discussing with their patients ways to manage the chronic diseases, then documenting in the patients record what diseases were addressed.

In Medicare Advantage, the quality metrics are focused on the STAR Ratings.  A small sample is extracted then extrapolated for the entire membership under each H plan number (Health Plan license number with the government).  By looking at the details of the components in the STAR ratings, it is easy to argue that the Medicare Advantage plans are merely gaming the system to achieve the results, rather than working with the PCPs in the practice of Population Healthcare.

STAR ratings are a combination of three elements, HEDIS 33, Health Outcome Surveys (HOS), and Consumer Assessment of Health Plans (CAHPS) that are tracked and reported by CMS on all Medicare Advantage Health Plans.  STAR Rating results will shift millions of dollars to or from Medicare Advantage Plans based on the results in the metrics.  The carrot and stick approach could be good, if the health plans actually controlled the results.  In reality, the health plans only control 4 out of 47 STAR metrics.  Conversely, Primary Care Physicians (PCPs) are directly responsible for 78% of the STAR ratings.  How can a health plan achieve a high STAR Rating, yet have no direct communication with the PCPs?

Applying Population Healthcare in practice will require PCPs to revert back to how they were trained in residency and away from the episodic medicine that the current reimbursement system has encouraged.  If a PCP captures the information and is actively managing all their patients’ chronic conditions, the health plan STAR Ratings will improve dramatically.  In simple terms, by doing the right thing for their patients, the PCP will help the Medicare Advantage plan succeed in meeting CMS’s “quality metrics.”

There are significant opportunities for improved collaboration between health plans and PCPs.  Finding ways to link the level of reimbursement to PCPs to reflect the additional work necessary to achieve enhanced STAR Ratings is key.  Absent this occurring, health plans will continue to chase the Red Herrings of quality as it is defined by CMS.



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