The Affordable Care Act of 2010 has transformed the health care landscape by providing strong incentives to insurers to improve the overall quality of care through the Five-Star Quality Rating System. The success of these incentives is demonstrated by the significant increase of insurers investing in quality initiatives. This, in turn, has driven healthy competition to develop strategic models that ensure both better outcomes and engagement by multiple stakeholders with aligned interests.
The Affordable Care Act (ACA) increased the incentives for quality under the Centers for Medicare and Medicaid Services’ (CMS) Five-Star Quality Rating System. In the process, the Act ushered in a transformation of the quality landscape not only for the 18.5 million beneficiaries expected to enroll in Medicare Advantage (MA) plans for 2017 but for the entire health care system as well.1 Since the ACA’s inception in 2010, insurers offering MA plans have escalated their efforts toward quality improvements to achieve higher ratings of their plans and earn higher financial bonuses. The magnitude of influence of star ratings on insurers was highlighted recently when stock prices for both Humana and Cigna significantly declined upon reports that they were likely to earn fewer incentives due to lower enrollment in highly rated MA plans.2 Thus, the impact of quality performance has clear consequences, not only for the beneficiaries participating, but for the insurers administering these plans. In the push to achieve higher star ratings, both CMS and insurers will need to evolve to foster “care creativity” that will impact and involve many stakeholders across the delivery system.
Medicare Advantage Plans
Comparative Analyses of Strategic Quality Performances
In 2009, 17% of MA enrollees were in four- and five-star plans, but in 2017 that number will increase to 68%.3 Nearly half (49%) of active, rated MA contracts earned four or five stars in the 2017 CMS rating.4
Winners among the MA plans included Kaiser and Aetna. Kaiser continued its stellar track record, with reports that its plans in California, Colorado, the Mid-Atlantic States, and the Pacific Northwest all earned the coveted five-star high-performing icon.4 Its commitment to integrated care,5 emphasizing in certain locations a fully coordinated, “under one roof,”6 patient-centered approach, continues to give Kaiser a performance edge, which is unsurprising to those who follow star ratings. Fully integrated systems such as Kaiser’s logically seem to have an advantage in achieving high ratings. However, a limited number of beneficiaries are enrolled in plans administered by fully integrated systems, at least in part due to their reduced availability nationwide.
Among publicly traded companies, Aetna had the highest percentage of Medicare members enrolled in plans rated 4.0 overall stars, and the 2017 star ratings saw an increase in membership enrollment in its four-star plans. The number of members enrolled in Aetna plans with a star rating of 4.0 or higher increased to 91%, up four percentage points from the previous year.7 Aetna highlighted its performance by averaging over 4.5 stars on quality measures such as “Controlling Blood Pressure in People with Hypertension,” “Controlling Blood Sugar in People with Diabetes,” and “BMI Assessments.”7 Notably offsetting Aetna’s lack of a fully integrated, “under one roof” care continuum (as compared with Kaiser) is its apparent commitment to fostering a culture of “care creativity.”8 A prime example of Aetna’s care creativity is issuing complimentary blood pressure monitors to help more members successfully get their high blood pressure under control.9
Replicating Care Creativity in CMS Models Nationwide
Select plans are being enlisted to participate in innovative CMS models such as the Medicare Advantage Value-Based Insurance Design (VBID). CMS will test VBID to assess whether structuring patient cost-sharing and other health plan design components leads to health care utilization by beneficiaries that improves health outcomes and reduces costs. The model will provide flexibility for select MA plans to develop clinically nuanced benefit packages for populations within certain categories, such as diabetes, chronic obstructive pulmonary disease, coronary artery disease, and mood disorders, with the addition of rheumatoid arthritis and dementia in 2018. The VBID model will permit select plans to enhance care coordination and eliminate some co-pays in an effort to improve member health. CMS recently announced nine MA plans selected to participate for 5 years, effective January 2017.10
Part D Plans
Comparative Analyses of Strategic Quality Performances
In 2009, 27% of prescription drug plan (PDP) enrollees were in four- and five-star plans, but in 2017 that number will increase to 41%.3 CMS has announced that for 2017, 49% of the PDPs have earned four stars or better.4 It is noteworthy, however, that although the same percentage (49%) of PDPs and MA plans have attained four-star status, the trajectory of membership growth in four- and five-star plans has been slower for the PDPs (27% to 41%) than for the MA plans (17% to 68%).
While the number of PDPs dropped by 16% from 2016 to the lowest in the program’s history,11 the number of PDPs that attained a five-star rating nevertheless grew from two in 2016 to six in 2017. Of the six plans with the prized five-star rating, only Tufts Insurance Company earned the rating in both 2016 and 2017.4 A nonprofit organization, Tufts is nationally recognized for its commitment to providing innovative, high-quality health care coverage.12 It is also noteworthy that four of the other Part D plans achieving the five-star high performing icon in 2017 were Blue Cross Blue Shield (BCBS) plans4:
• Anthem Insurance Co. & BCBSMA & BCBSRI & BCBSVT
• Excellus Health Plan, Inc.
• BCBS of Michigan Mutual Insurance Company
• Wellmark IA & SD, & BCBS MN, MT, NE, ND, & WY
BCBS plans are expanding their collaborations to deliver greater care creativity in the marketplace. As a case in point, Blue Cross Blue Shield Association was recently recognized by Fast Company as one of the world’s most innovative organizations in data science for its Blue Cross Blue Shield AxisSM product. The tool will leverage data from all 36 of its plans to provide information on cost and quality to facilitate value-based health care decisions.13
Replicating Care Creativity in CMS Models Nationwide
The 2017 Star Ratings reported that scores on the Part D quality measure “Medication Therapy Management (MTM) Program Completion Rate for Comprehensive Medication Review” were as low as 25.3% (PDP numeric average) with a less than three-star average.14 It is therefore not surprising that CMS recently announced a pilot of the Part D Enhanced Medication Therapy Management (Enhanced MTM) model to assess whether providing a select group of PDPs with further incentives and flexibilities to launch innovative programs will improve medication use among beneficiaries. The pilot program will run for 5 years starting in January 2017 and is designed to investigate whether the enhanced model leads to better health care and outcomes for patients and whether it potentially lowers health care costs overall.15
Further improvements will be challenging to achieve, especially for those operating outside fully integrated health care systems; however, this will incentivize various stakeholders to develop innovations aimed at better clinical performance. For example, novel information platforms are already available to pharmaceutical and life science companies to help identify performance gaps among health and drug plans using quality metric and performance aggregator tools.16,17 These tools can assist companies in identifying and addressing clinical/medical gaps on key quality metrics at both the therapeutic and process levels, in areas such as diabetes care and medication adherence.
Another field that is open to development will be innovations in new service models that advance adherence and patient engagement by free-standing, complex condition-management and health-coaching organizations. New pathways to patient engagement are being forged by community pharmacies with support from electronic platforms promoting MTM18 and by web services using algorithmically minded virtual nurses19 or virtual health assistants20 to promote medication adherence through electronically assisted problem-solving. Technology behemoths such as Apple (biofeedback devices),21 Google (Deep Mind),22 and IBM (Watson Health)23 are paving the way to the promise of personalized care through delivery of predictive modeling algorithms based on individualized patterns of adherence and nonadherence.
Even with a transition from a Democratic to a Republican administration, we are likely to see a continued emphasis on value-based models. As a case in point, Speaker of the House Paul Ryan’s 2016 “A Better Way” proposal references the Star Rating program, and includes value-based insurance design throughout the MA program.24 Insurers, integrated health systems, and the broader health care system can expect that CMS will continue to drive performance for greater value by using models that encourage clinical innovation and foster a culture of care creativity. These initiatives will accelerate the innovative use of strategic quality by plans to improve member satisfaction and retention, market differentiation and share, and profitability. As a result, the engagement of multiple stakeholders with aligned interests is likely to grow further in an effort to improve performance.
1. Cavanaugh S. Improved quality of Medicare health and drug plans means great news for Medicare beneficiaries. The CMS Blog. Published October 12, 2016. Accessed November 4, 2016.
2. Muchmore S, Aguilar A. Humana, Cigna hit by lower 2017 Medicare star ratings. Modern Healthcare. Published October 12, 2016. http://www.modernhealthcare.com/article/20161012/NEWS/161019958. Accessed November 14, 2016.
3. Morse S. Enrollment in 4 or 5-star Medicare Advantage plans rising, new star ratings show. Healthcare Finance. Published October 12, 2016. http://www.healthcarefinancenews.com/news/enrollment-4-or-5-star-medicare-advantage-plans-rising-new-star-ratings-show. Accessed November 14, 2016.
4. Centers for Medicare & Medicaid Services. 2017 star ratings. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-12.html. Published October 12, 2016. Accessed November 4, 2016.
5. Business Wire. Kaiser Permanente’s Medicare health plan in California receives top 5-star rating for quality and service. http://www.businesswire.com/news/home/20161013006462/en/Kaiser-Permanente’s-Medicare-Health-Plan-California-ReceivesRef. Accessed November 4, 2016.
6. Kaiser Permanente. Kaiser Permanente Medicare plans receive top quality and service ratings. https://share.kaiserpermanente.org/article/kaiser-permanente-medicare-health-plans-receive-top-scores-quality-service/. Published October 16, 2016. Accessed November 4, 2016.
7. Business Wire. Aetna’s stars are shining as CMS announces Medicare quality ratings. http://www.businesswire.com/news/home/20161012006259/en/Aetna’s-Stars-Shining-CMS-Announces-Medicare-Quality. Published October 12, 2016. Accessed November 4, 2016.
8. Mamula KB. New Medicare Advantage plans to target diseases such as diabetes, high blood pressure. Pittsburgh Post-Gazette. Published October 5, 2016. http://www.postgazette.com/business/healthcare-business/2016/10/05/New-Medicare-Advantage-plans-to-be-introduced-in-2017/stories/201610050108. Accessed November 4, 2016.
9. Silverlink. Aetna and Silverlink help seniors more successfully monitor and control their hypertension. http://www.silverlink.com/pr/111511.html. Published November 15, 2011. Accessed November 4, 2016.
10. Centers for Medicare & Medicaid Services. Medicare Advantage value-based insurance design model. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-03-2.html. Published October 3, 2016. Accessed November 4, 2016.
11. Hoadley J, Cubanski J, Neuman T. Medicare Part D: a first look at prescription drug plans in 2017. Kaiser Family Foundation website. http://kff.org/report-section/medicare-part-d-a-first-look-at-prescription-drug-plans-in-2017-findings/. Published October 17, 2016. Accessed November 4, 2016.
12. Tufts Health Plan. About us. https://tuftshealthplan.com/about-us. Accessed November 4, 2016.
13. Blue Cross Blue Shield. Fast Company. https://www.fastcompany.com/company/blue-cross-blue-shield. Accessed November 4, 2016.
14. Centers for Medicare & Medicaid Services. Medicare 2017 Part C & D star rating technical notes. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2017_Technical_Notes_preview_1_2016_08_03.pdf. Published August 3, 2016. Accessed November 4, 2016.
15. Centers for Medicare & Medicaid Services. Participants selected for Part D enhanced medication therapy management model. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-03.html. Published October 3, 2016. Accessed November 4, 2016.
16. Precision for Value. QNAVTM navigating quality measures and performance data. http://www.precisionforvalue.com/qnav/. Accessed November 4, 2016.
17. National Committee for Quality Assurance. Quality Compass. http://www.ncqa.org/hedis-quality-measurement/quality-measurement-products/quality-compass. Accessed November 4, 2016.
18. Lasota ST, McConaha JL, Lynch KL, Greco AJ. Implementation strategy to bring medication therapy management into high-volume community pharmacies. Am J Pharm Benefits. http://www.ajpb.com/journals/ajpb/2015/ajpb_marchapril2015/implementation-strategy-to-bring--medication-therapy-management-into-highvolume-community-pharmacies. Published April 20, 2015. Accessed November 4, 2016.
19. Côté J, Rouleau G, Ramirez-Garcia P, Bourbonnais A. Virtual nursing intervention adjunctive to conventional care: the experience of persons living with HIV. JMIR Res Protoc. 2015;4(4):e124.
20. Morrow T. How virtual health assistants can reshape healthcare. Forbes. Published March 13, 2013. http://www.forbes.com/sites/ciocentral/2013/03/13/how-virtual-health-assistants-can-reshape-healthcare/#6b461d788514. Accessed November 4, 2016.
21. Hughes N. Rumor: Apple working on entirely new, advanced health-tracking hardware for 2017 launch. Apple Insider. Published August 9, 2016. http://appleinsider.com/articles/16/08/09/rumor-apple-working-on-entirely-new-advanced-health-tracking-hardware-for-2017-launch. Accessed November 4, 2016.
22. Condliffe J. DeepMind will use AI to streamline targeted cancer treatment. MIT Technology Review. Published August 31, 2016. https://www.technologyreview.com/s/602277/deepmind-will-use-ai-to-streamline-targeted-cancer-treatment/. Accessed November 4, 2016.
23. Lorenzetti L. Here’s how IBM Watson Health is transforming the health care industry. Fortune. Published April 5, 2016. http://fortune.com/ibm-watson-health-business-strategy/. Accessed November 4, 2016.
24. A better way: our vision for a confident America. Published June 22, 2016. https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf. Accessed December 5, 2016.