Last October, EmblemHealth's Medicare Advantage HMO became the first Advantage plan in New York City to achieve a coveted four-star rating from the CMS.
That was the result of four years of work to improve the HMO's quality measures, said John Kennedy, the for-profit insurer's vice president for direct-to-consumer sales. Now, if EmblemHealth officials notice that an enrollee with diabetes is overdue for blood tests, they'll reach out to the member and doctor to encourage them to schedule an appointment. “I think (members) sense that the health plan is really concerned about their quality of care,” Kennedy said.
The four-star rating (on a scale of 1–5) allows EmblemHealth to receive bonus payments from the CMS at a time of heightened rate pressure on Medicare Advantage plans. The bonuses typically amount to an increase of a couple of percentage points—$281 per enrollee in 2012, according to the Kaiser Family Foundation. That amount can make the difference between profit and loss in a narrow-margin business.
Despite widespread projections that Medicare's reduced payments to Advantage plans mandated by the Patient Protection and Affordable Care Act would lead to enrollment reductions, private Medicare plans are booming. Currently, there are nearly 15.9 million seniors enrolled in Advantage plans, compared with 11.4 million in 2010, an increase of almost 40%. Nearly one-third of all Medicare beneficiaries now are enrolled in Advantage plans, with roughly two-thirds of them opting for HMO products.
The Congressional Budget Office projects Advantage enrollment will hit 21 million by 2023.