Medicare Advantage plans look for physician buy-in on five-star rating system

With potential bonus payments now at stake, Medicare Advantage plans are getting serious about quality improvement, and they want doctors' help. But it's unclear to what degree the health plans will share the rewards of those efforts with physicians.

Health plans' efforts to earn five-star status -- indicating a high-quality Medicare Advantage plan -- from the Centers for Medicare & Medicaid Services are likely to require physicians' participation.

"Physician engagement is imperative to becoming a five-star plan," said Dan Mendelson, president and chief executive officer of Avalere Health, a group of health care-focused business and policy analysts in Washington, with clients including government, health plans and physician practices.

"A lot of the activity that has happened so far has been focused on what the plan can actually control -- the call center, etc. Really, the next phase is physician engagement," Mendelson said. "Physicians can expect to be hearing from the plans, both from letters -- which they love getting -- and contractually, plans approaching them and saying, 'We want you to take on some risk.' "

Under the Patient Protection and Affordable Care Act, the government is reducing Medicare Advantage payments to a level closer to traditional fee-for-service Medicare.

But Medicare Advantage plans can make up for those cuts by demonstrating their ability to coordinate care, manage chronic illness and respond to customers' questions. Plans are awarded one to five stars based on their scores on Healthcare Effectiveness Data and Information Set quality measures, Consumer Assessment of Healthcare Providers and Systems survey results and other measures. The measurement and stars came into existence in 2007, but interest in the program picked up with the introduction of financial bonuses. Five-star plans can receive bonuses of up to 5% additional reimbursement and up to 10% in "double bonus" counties.

Under the health system reform law, plans must use the bonuses to increase benefits or lower premiums for members. The high-scoring plans also will have a competitive advantage in 2012, because their five-star status allows them to enroll members year-round rather than at specific enrollment periods.

CMS awarded five stars to only nine out of 569 plans. Open enrollment for 2012 runs from Oct. 15 to Dec. 7, 2011. Four plans are run by California-based integrated health system Kaiser Permanente.

The others included: Advocare plans, sponsored by Marshfield (Wis.) Clinic; Gunderson Lutheran Health Plan in LaCrosse, Wis.; Group Health Cooperative in Seattle; Baystate Health's Health New England in Springfield, Mass., and Martin's Point Health Care in Portland, Maine. The Kaiser plans are the largest, with a combined 767,669, and Baystate's is smallest, with 5,349.

David Howes, MD, president and CEO of Martin's Point Health Care, said physicians are central to health plans' efforts to improve members' experience and care and thus reach five-star status. Smaller, integrated, community-focused plans have an advantage in the quality improvement race because of their size and customer focus, he said. The nine five-star plans are HMOs affiliated with hospital and physician organizations.

But that doesn't mean it will be impossible for larger plans to reach five-star status. A Barclays Capital Research report put the average of Medicare Advantage plans at 3.56 stars, up 0.11 from 2010.

"Large carriers have the resources and the knowledge to essentially bring themselves into alignment with a much larger movement and to move it ahead much more quickly," Dr. Howes said. "I think the big plans can get there."

The big plans are working on it.

UnitedHealthcare is among those enlisting physicians' help, said Rhonda Medows, MD, chief medical officer and executive vice president. The Barclays note put United's 68 plans at an average of 3.19 stars.

"Health plans have always been focused on improving quality for our members," Dr. Medows said in a statement. "The new dynamic is that plans are now being asked to provide much more support to the health care delivery setting. One way we're doing this is by providing physicians with actionable data through online portals and mailings." This data will help them identify any gaps in care related to prevention, wellness and chronic disease -- such as if a patient is due for a mammogram or a physical, she added.

If that sounds a lot like many other quality improvement efforts, that's not a coincidence. But similarity among efforts aimed at achieving a five-star rating, and many other quality-improvement and pay-for-performance plans, could be helpful to physicians who are required or asked to participate in them.

If those programs do not exactly overlap or align, physicians could be stuck trying to measure a dozen different things for a dozen different plans.

Besides the risk of running doctors ragged with quality improvement efforts, there is the question of whether health plans will pass along some of the financial gains they make thanks to those efforts.

Mendelson said he expects they will.

"Health plans know physicians are motivated by payment systems," he said. "Physicians tend to follow the incentives much like anyone does."