Medicare Advantage plans may see the Five-Star Ratings system as a salve for falling federal reimbursements, but MCO executives who assume they will cash in on quality should check on what this data is saying. In some cases, data measuring Medicare Advantage plans ability to tackle individual conditions leaves much to be desired, and this could leave money on the table for some plans.

In theory, MA plans welcome being paid extra based on quality because this favors the best performers and helps offset expected reimbursement cuts. Under the ratings system, top-performing plans could receive bonuses of up to 5 percent based on various measures, but a look at the underlying data highlights some gaps in the current system.

Although MA plans are strong at some big-picture things access to primary-care physicians, maintaining long-term physical health and monitoring long-term drug use they fall short on specific conditions such as osteoporosis and chronic obstructive pulmonary disease. Let's take COPD as an example. CMS wants testing to confirm if a beneficiary has COPD, a costly condition afflicting seniors that can result in them being hospitalized or worse if untreated. As a result, CMS is measuring whether health plan members are receiving their COPD test, and this measure helps determine plans overall score and bonus amounts.

Confirming COPD is fairly straightforward. With a spirometer, a primary-care physician or specialist can diagnose the condition by the amount of airflow a patient can exhale in a set time. However, in the most recent ratings, only 28 percent of MA plans beneficiaries got this test. In comparison, 88 percent of diabetics received kidney disease monitoring. In fact, only one plan nationally Universal Care's Brand New Day received all five stars for COPD confirmation. In comparison, 50 plans received one star, the lowest possible score, indicating that tests occur fewer than 20 percent of the time. These low-performing plans include some of the biggest insurers in the nation, such as UnitedHealth Group, Aetna, Humana and HealthSpring. As a result, the average star received for COPD tests was just 2.1 out of 5, compared with 3.9 for monitoring patients long-term medications.

The reason, health plans say, is that primary-care physicians may be more likely to treat respiratory ailments based on symptomology rather than spirometry, causing them to miss some COPD diagnoses. However, this is why Medicare Advantage plans exist, to provide care coordination and ensure that tests don't fall through the cracks. Instead, Medicare Advantage plans have yet to fill in those cracks, resulting in beneficiaries getting care that isn't much better than fee-for-service Medicare.

There are other red flags. Scores for improving or maintaining seniors mental health are even worse than for COPD. So how do we fix this? Health plans are already starting to do their part, leveraging their data infrastructure to identify t beneficiaries in need of tests. But more importantly, health plans must start including these measures in the quality bonuses they pay providers. Otherwise, insurers will continue to allow gaps in care and leave their own bonus money on the table.

Six healthcare policy questions hanging in the balance as the United States votes

View Now