Federal rankings for cost-saving Medicare Advantage Plans improve when adjusted for race, neighborhood poverty and social risk, increasing reimbursement rates for companies offering them, which can improve their availability to people with low incomes, a recent study by two Brown University researchers shows.
Without such adjustments, Medicare Advantage Plan rankings may not accurately reflect the quality of care a given plan’s enrollees receive, said Amal Trivedi, an associate professor of health services, policy and practice at Brown, co-author of “Impact Of Risk Adjustment For Socioeconomic Status On Medicare Advantage Plan Quality Rankings,” published July 9 in the journal Health Affairs.
Centers for Medicare & Medicaid Services currently measures quality in 30 categories, including customer service, efficiency in processing claims and appeals, disease screening rates and patients’ body-mass indexes. Each plan’s performance in these categories contributes to an overall ranking score of between one and five stars. Trivedi and co-author Shayla M.N. Durfey, third-year medical student at the Warren Alpert Medical School of Brown University, adjusted three of those categories: blood-pressure control, cholesterol control and diabetes control, to account for the effect of low-income and social factors: sex, race/ethnicity, dual eligibility, disability, rurality and neighborhood disadvantage.
Disadvantaged patients – those with lower income and members of minority groups – have worse outcomes on some quality measures, said Durfey. Those populations disproportionately suffer from uncontrolled high blood pressure, high cholesterol levels and diabetes. If a plan is made up of disadvantaged individuals from these categories, the plan is more likely to have poor blood pressure, diabetes and cholesterol control, she said.
“To control diabetes, for example, you need things [such as] good health literacy, access to healthy foods and access to money that buys healthy foods,” Durfey said. “If you live somewhere rural and have a low-paying job, you have fewer healthy choices near you, and they’re often too expensive to consider.”
Durfey said researchers entered the social-risk factors into a statistical computer model that adjusted for the risk factors in ranking Medicare Advantage Plans, so they were judged on quality for those criteria rather than according to the socio-economic risk involved.
“This is sort of like taking the risk out of the equation,” Durfey said. “In other words, the adjusted scores represented the proportion of enrollees in a plan that would have controlled blood pressure, diabetes or cholesterol if social-risk factors were accounted for. We then compared the nonadjusted and adjusted scores and looked at the difference. Lastly, we confirmed that the plans that improved in rank were made up of larger proportions of disadvantaged enrollees.”
The resulting quality rankings, Durfey said, were adjusted so the plans competed on an even level based on the quality of the plans, not on whether the people using the plans had better access to exercise, healthy food and a better understanding of their health. After the adjustments, many lower-ranked plans moved substantially higher in the rankings.
That level of accuracy in the quality rankings is important, Trivedi said, 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: All its enrollees receive a letter encouraging them to switch to better plans, he said.
If companies offering Medicare Advantage Plans notice a connection between low rankings and their socio-economically disadvantaged enrollees, they’ll have little incentive to continue serving the underserved.
“Medicare plans can’t deny coverage to anyone with a pre-existing condition, but they can operate in areas that are more affluent or have healthier, less-disadvantaged populations, leaving poor and rural populations with fewer and fewer options,” Trivedi said.
In Rhode Island, there were 81,724 people enrolled in Medicare Advantage programs in 2018, according to CMS.gov data, with 15 Medicare Advantage Plans available.
At Blue Cross & Blue Shield of Rhode Island, which serves 54.7 percent of the Medicare Advantage market in Rhode Island, news of the study and the possibility of more-accurate rankings, while well-received, didn’t appear to be a game-changer.
“Generally speaking, we support anything that leads to more-equitable rankings. This research does not impact our participation in the Medicare Advantage program. We are dedicated to finding solutions that address each unique member’s needs,” said Eddie Walker, managing diretor of Medicare at Blue Cross.
