Medicare Advantage plans that draw a lot of their enrollment from the poor side of town say they're at a disadvantage on the government's five-star ratings scale, which commands respect and governs pay.
One company pressing the issue is WellCare Health Plans, based in Tampa. Its Medicare Advantage plans are rated at 3 or 3 1/2 stars, below the 4-star minimum required for plans to qualify for bonus payments. Plans' premium and bonus payments are kept confidential, but other media report that the bonuses amount to a few hundred dollars per member.
When the federal Centers for Medicare and Medicaid Services (CMS) released new star ratings in October, WellCare issued a statement saying the scale "unfairly penalizes plans focused on serving low-income, medically complex members."
WellCare prepared and published a six-page "white paper" outlining reasons it thinks the current ratings are unfair. It outlined studies that provided ammunition for the argument and called for CMS to adjust more of its quality measures to account for the problem.
"Dual-eligibles" -- Medicare patients with incomes so low state Medicaid programs cover whatever Medicare doesn't pay -- need a separate rating system, WellCare said. Only 416,000 of its 4 million members are in Medicare Advantage plans, according to company documents. WellCare has 2.3 million in Medicaid programs and 1.4 million in Medicare prescription drug plans.
CMS was paying attention to the Medicare Advantage ratings dispute even before it issued the latest round. In September, the agency issued a formal request for information on whether income disparity throws off the rating methodology. It also funded a study by the National Quality Forum, a group working on improvements in health care.
Last week during an earnings call with analysts, Chairman and CEO Dave Gallitano said the company has improved its ratings in many Medicare Advantage plans from 3 to 3 1/2 stars. He promised to do whatever it takes to move up to 4 stars but said it's a challenge, given the demographics of its membership: The company's proportion of dual eligibles is high, around 50 percent.
"There are inherent challenges in treating this population," Gallitano said.
For example, it's an argument similar to that of schools in disadvantaged areas explaining low scores on standardized tests, similar to that of hospitals with low-income populations explaining high readmission rates.
To be sure, some Florida high-scoring Medicare plans seem to have a large proportion of dual eligibles. Among them: CarePlus, Florida's only 5-star plan, and Simply Healthcare, with 4 stars. Figuring out what makes some plans more successful with low-income populations is an evolving business.
A study published last month by the data analytics company Inovalon found significant differences in quality measures between dual-eligible populations and other Medicare patients. For example, duals were less likely to take anti-depressants and other drugs as prescribed, the study said; the worst compliance was found among patients who were disabled, had substance abuse or lived in doctor-shortage areas.
WellCare was one of the companies that provided data for the study.
Medicare's 5-star scale, like private employers' pay-for-performance ratings, prods plans to provide better value and to guide patients to enroll in cost-effective plans. The number of stars is listed beside the name of the plan at www.medicare.gov.
In searching for lowest-cost Medicare Advantage plans, Floridians in several metro areas come up with WellCare or Coventry, companies that market HMOs with zero premium and expanded benefits. But similarly priced plans are available from Humana or Freedom that can boast 4 or 4 1/2 stars.
Blair Todt, WellCare's chief strategy and development officer, says the other companies have a more favorable "sociodemographic status," which includes race, gender, income and education levels.
"It's a little bit unfair to have a scoring system that doesn't account for the sociodemographic status of these members," Todt says.
About 50 categories are used in creating the five-star plan ratings. They include medical measures as determined by the independent National Committee for Quality Assurance and other groups, and attitude surveys from the Consumer Assessment of Healthcare Providers and Systems, performed by CMS.
Todt explains that while a health plan can drive some measures, such as answering customer calls or seeing a sick patient within a certain length of time, those that depend in part on patient compliance can be more challenging.
Some patients who qualify for both Medicaid and Medicare patients are elderly or physically disabled. They may have trouble getting around without help and may not feel like going out. They may not speak English.
Another big group of dual-eligibles qualify because they are mentally ill or addicted to drugs or alcohol, Todt said. Some of these are homeless or in temporary facilities. They may have been auto-assigned to a plan because they didn't sign up, and may have never met their primary-care physician.
In dealing with such populations, plans do what they can, Todt said. They provide transportation to the doctor, mail prescriptions, and have case managers who call to check on them. But they can't force patients to take their medicine.