The CMS is working to develop a separate star-rating system for health plans participating in an Obama administration experiment intended to better manage benefits and care for low-income and disabled Americans.
In a Nov. 6 notice sent to plans (PDF) participating in state-administered demonstrations, the CMS outlines how the star system would be structured and what quality measures would be included.
However, the ratings would only be created if the CMS decides to expand the initiative, and that will only happen if the demonstrations actually improve the quality of care for beneficiaries and save money.
There is no timeline for such a decision. It will be years before the agency has collected enough data to determine whether the results warrant expanding the program. Until then, the CMS plans to post quality performance data, including how dual plans compare with one another, starting next year on the Medicare-Medicaid Coordination Office website.
Although participating health plans say they generally support the idea of a unique rating system, some are concerned that the CMS won't get it right.
“The challenge CMS faces is to create a rating system that accurately reflects the needs of individuals and delivery of care across the two programs,” Cigna spokeswoman Katie Sulkowski said.
Twelve states have rolled out three-year demonstrations under the Affordable Care Act program, called the Financial Alignment Initiative. The goal of the program is to better coordinate the health benefits provided to Americans who are eligible for both Medicare and Medicaid and as a result receive splintered care at extremely high costs to both programs.
The CMS also released a notice Nov. 12 outlining ways to alter the overall Medicare Advantage rating system (PDF) to make it more fair to plans that enroll large numbers of dual eligibles, such as those designated by the agency as Dual Eligible Special Need Plans (or D-SNPs).
When the dual demonstrations launched, states were allowed to passively enroll people into plans. That is, when eligible residents didn't pick a plan or decline to participate, the state could assign them to one.
Now any new participants have to actively choose a plan and can jump to a different one at any time. With these factors in mind, stakeholders say it's important that the plans have their own quality ratings.
“With so many options available, the star-rating system provides consumers with an easy way to understand the quality of the health plans they can choose,” said Seth Diamond, chief operating officer at New York-based MetroPlus Health Plan.
A separate rating system also makes sense because dual plans also cover a much wider range of benefits than Medicare does, including Medicaid long-term supports and services and behavioral health services, noted James Verdier, a senior fellow at Mathematica Policy Research, a research and policy evaluation organization.
The agency is asking for input on the proposal by Dec. 21.
Initial reaction to both the star system and the CMS' plan to post quality data about the plans have been mixed so far.
“We are pleased that CMS has acknowledged the challenges that come with serving the country's most vulnerable residents,” said Elizabeth Goodman, vice president of public policy and government affairs at WellCare.
Lisa Rubino, senior vice president of dual-eligible strategy at Molina Healthcare, said a new rating framework would help evaluate the benefit of coordinating care for duals. “We need to figure out if people are getting better from this,” Rubino said.
There are substantial concerns, however, about how the new star system would be implemented and whether the measures would be accurate, fair and actionable, said Meg Murray, CEO of the Association for Community Affiliated Plans.
And some question the need for a separate rating system.
“The dual eligible demonstrations are extraordinarily complex to set up and administer, with enrollment well below expectations,” said Kip Piper, a Washington-area consultant and former senior official at the CMS. “The new framework will further increase the complexity of the programs, with CMS' traditional overemphasis on process and procedure.”
Some plans are also concerned about the agency's interim plan to publish performance data and comparisons. “CMS has been opaque on exactly which measures would be used for this effort, and plans need the opportunity to know about and comment on which measures CMS would intend to use,” Murray said.