CMS Star Ratings' Quality Bonus Payments Can Mean Survival for Health Plans

The quality bonus payments tied to CMS’ star ratings makes it critical that health plans receive a 4 or better, Jonathan Harding, MD, chief medical officer of the Senior Products Division at Tufts Health Plan, said at the America’s Health Insurance Plan’s National Conferences on Medicare and Medicaid, and Dual Eligibles Summit in Washington, DC, from September 28 to October 2.

Dr Harding explained that since CMS introduced the bonus payments, Tufts Health Plan has decided to abandon efforts to remain on other rankings and instead focus its efforts on the star rating. While the plan is always striving to get a 5-star rating, it’s critical to be a 4 or higher, so that is where Tufts is focusing energy. Tufts Health Plan received 4.5 stars for its Tufts Medicare Preferred HMO and Senior Care Options based on the CMS star ratings for 2015.

“Our profit margin is less than the star bonus amount,” he said. “So really it’s the difference between survival and not.”

The Healthcare Effectiveness Data and Information Set, known as the HEDIS measures, are the largest set of measures that apply to Medicare, and ones that Tufts Health Plan tends to do well in. The patient experience measures are also a large part of the ratings, Dr Harding explained. But neither of them are particularly difficult for plans to improve upon.

The Health Outcomes Survey metrics are usually the hardest set of measures to move, according to Dr Harding. These measures are influenced by patient self-reported measures and health outcomes.

“Those are very hard to influence … because we have no idea who is going to be surveyed, and so we have to address the whole population,” he said.

Further complicating the measures is the fact that they aren’t in anything close to real time. Patients can be surveyed between 4 and 2 years ago, then that information needs to be reported to get into the star ratings, Dr Harding explained.

“So it’s really hard to move them over a short period of time,” he said. “It really takes forethought and long-term planning.”