Higher Medicare Advantage Star Ratings Are Associated With Improvements In Patient Outcomes

Association of Social Vulnerability and Access to Higher Quality Medicare Advantage Plans

BACKGROUND

With more than half of all beneficiaries enrolled in Medicare Advantage (MA) plans, ensuring access to high-quality MA plans is a key concern for policymakers. Access to high-quality MA plans may be limited in certain areas if private insurers are not willing to offer high-quality MA plans in local areas with greater unmet health-related social needs.

OBJECTIVE

This study examined the association of a market-level social vulnerability index (SVI) score with the number of high-quality MA plans.

DESIGN

This study conducted a retrospective cross-sectional study.

PARTICIPANTS

Our analysis included 3113 USA counties in 2020.

MAIN MEASURES

Our primary outcome measure, the availability of high-quality MA plans at the market level, was defined by counting the raw number of 5-star plans, plans with 4.5 or higher stars, and plans with 4 or higher stars. We also counted the number of all MA plans at the market level as an outcome measure to explore private insurers' market entry and participation decisions.

RESULTS

We found evidence that fewer high-quality MA plans are available in markets with greater unmet social needs (higher SVI scores). Compared to the least vulnerable markets, the most vulnerable markets had 1.5 fewer MA plans overall [95%CI -2.9, -0.1]. The most vulnerable markets also had 1.1 fewer 4 or higher star plans [95%CI -1.9, -0.3] than the least vulnerable markets. Furthermore, this negative association was concentrated in the southern region, which has a greater proportion of Black/African Americans in its market-level populations.

CONCLUSION

As historically marginalized groups are more likely to reside in markets with greater unmet social needs, disparities in access to high-quality MA plans may widen existing health disparities. Therefore, monitoring the availability of high-quality MA plans in areas with greater unmet social needs is needed to improve health equity for MA beneficiaries.

The influence of medication adherence on Medicare Star Ratings: A decade-long analysis of health plan performance

BACKGROUND

The Medicare Star Ratings Program, managed by the Centers for Medicare & Medicaid Services, assesses Medicare health plan performance. This program consists of quality measures that evaluate plan performance for both Medicare Part C and Part D, including 3 key medication adherence measures.

OBJECTIVE

To assess the potential relationship between performance on medication adherence measures and overall star rating performance for Medicare Advantage (MA) health plans.

METHODS

An analysis was conducted using annual Medicare Star Rating health plan performance data from 2015 to 2024 to assess the impact of performance on medication adherence measures on health plan overall star rating. Numerical percentages were calculated to assess the rates of a health plan achieving at least a 4-star overall rating if they achieved 4 or more stars, as well as a 5-star rating on each medication adherence measure or composite measure.

RESULTS

From 2015 to 2024, 4,213 health plan contracts received a star rating, of which 2,076 achieved at least a 4-star overall rating (49.3%). For plans achieving at least 4 stars on the medication adherence measures, 70%-74% of them also achieved at least a 4-star overall summary rating, depending on the specific measure. Among plans achieving 5 stars on any adherence measure, 85%-90% of them achieved at least a 4-star overall rating.

CONCLUSIONS

Assessing a decade of the Medicare Star Rating performance data showed that MA health plans that performed well on the medication adherence measures also had a high rate of achieving a 4-star overall rating. Future research should explore the interplay between medication adherence measures and other Medicare Star Rating criteria.

No Association Between Medicare Advantage Providers' Network Restrictiveness and Star Rating Between 2013 and 2017: An Observational Study

BACKGROUND

Medicare beneficiaries are increasingly enrolling in Medicare Advantage (MA), which employs a wide range of practices around restriction of the networks of providers that beneficiaries visit. Though Medicare beneficiaries highly value provider choice, it is unknown whether the MA contract quality metrics which beneficiaries use to inform their contract selection capture the restrictiveness of contracts' provider networks.

OBJECTIVE

We evaluated whether there are meaningful associations between provider network restrictiveness (across primary care, psychiatry, and endocrinology providers) and contracts' overall star quality rating, as well as between network restrictiveness and contracts' performance on access to care measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

PARTICIPANTS

Medicare Advantage contracts with health maintenance organization (HMO), local preferred provider organization (PPO), and point of service (POS) plans with available data.

DESIGN

A cross-sectional analysis using multivariable linear regressions to assess the relationship between provider network restrictiveness and contract quality scores in 2013 through 2017.

MEASURES

Statistical significance in the relationship between network restrictiveness and contract performance on quality measures.

RESULTS

Across all study years, we included 562 unique contracts and 2801 contract-years. We find no evidence of consistent relationships between MA physician network restrictiveness and contract star rating. For primary care, psychiatry, and endocrinology, respectively, a 10 percentage point increase in restrictiveness was associated with a 0.02 (95% confidence interval [CI] -0.01 to 0.04), 0.0008 (95% CI, -0.01 to 0.02), and -0.01 (95% CI, -0.01 to 0.001) difference in star rating (p-value > 0.05 for all). Similarly, we find no evidence of consistent relationships between network restrictiveness and access to care measures.

CONCLUSIONS

Our findings suggest that existing MA contract quality measures are not useful for indicating differences in network restrictiveness. Given the importance of provider choice to beneficiaries, more specific metrics may be needed to facilitate informed decisions about MA coverage.

Flaws in the Medicare Advantage Star Ratings

This Viewpoint discusses the limitations of the Medicare Advantage star rating system in identifying Medicare Advantage plans that deliver high-quality care.

Medicare Advantage Plan Star Ratings and County Social Vulnerability

Importance

The star rating of a Medicare Advantage (MA) plan is meant to represent plan performance, and it determines the size of quality bonuses. Consumer access to MA plans with a high star rating may vary by the extent of social vulnerability in geographic regions.

Objective

To examine the association between a county's Social Vulnerability Index (SVI) and the star rating of a county's MA plans.

Design, Setting, and Participants

This cross-sectional study used 2023 Centers for Medicare & Medicaid Services data for all MA plans linked to 2020 county-level SVI data from the Centers for Disease Control and Prevention. Data were analyzed from March to October 2023.

Exposure

Quintile rank of county based on composite and theme-specific SVI scores, with quartile 1 (Q1) representing the least vulnerable counties and Q5, the most vulnerable counties. The SVI is a multidimensional measure of a county's social vulnerability across 4 themes: socioeconomic status, household characteristics (such as disability, age, and language), racial and ethnic minority status, and housing type and transportation.

Main Outcomes and Measures

County-level mean star rating and the number of MA plans with low-rated (<3.5 stars), high-rated (3.5 or 4.0 stars), and highest-rated (≥4.5 stars) plans.

Results

Across 3075 counties, the median county-level star rating was 4.1 (IQR, 3.9-4.3) in Q1 counties and 3.8 (IQR, 3.6-4.0) in Q5 counties (P < .001). The mean star rating of MA plans was lower (difference, -0.24 points; 95% CI, -0.28 to -0.21 points; P < .001), the number of low-rated plans was higher (incidence rate ratio, 1.81; 95% CI, 1.61-2.06; P < .001), and the number of highest-rated plans was lower (incidence rate ratio, 0.75; 95% CI, 0.70-0.81; P < .001) in Q5 counties compared with Q1 counties. Similar patterns were found across theme-specific SVI score quintiles and for 2022 star ratings.

Conclusions and Relevance

In this cross-sectional study, the most socially vulnerable counties were found to have the fewest highest-rated plans for MA beneficiaries. As MA enrollment grows in socially vulnerable regions, this may exacerbate regional differences in health outcomes for Medicare beneficiaries.

Impact of star ratings on Medicare health plan enrollment: A systematic literature review

BACKGROUND

The Medicare star ratings program was developed by the Centers for Medicare and Medicaid Services in 2007 as an approach to evaluate health plan performance and quality.

OBJECTIVE

This study aimed to identify and narratively describe studies that attempted to quantitatively assess the impact that Medicare star ratings have on health plan enrollment.

METHODS

A systematic literature review (SLR) was conducted of PubMed MEDLINE, Embase, and Google to identify articles that quantitatively assessed the impact of Medicare star ratings on health plan enrollment. Inclusion criteria consisted of studies that conducted quantitative analyses to estimate the potential impact. Exclusion criteria consisted of qualitative studies and studies that did not directly assess plan enrollment.

RESULTS

This SLR identified 10 studies that sought to measure the impact of Medicare star ratings on plan enrollment. Nine of the studies found that plan enrollment increased in accordance with increases in star ratings or that plan disenrollment increased with decreases in star ratings. One study conducted of data before the implementation of the Medicare quality bonus payment found contradictory results from one year to the next, whereas all the studies that assessed data after implementation found increases in enrollment in accordance to increases in star ratings or increases in disenrollment for decreases in star ratings. One concerning finding from some of the articles included in the SLR is that increases in star ratings had less of an impact on enrollment in higher-rated plans for ethnic and racial minorities and older adults.

CONCLUSIONS

Increases in Medicare star ratings led to statistically significant increases in health plan enrollment and decreases in health plan disenrollment. Future studies are needed to assess whether this increase has a causal association or is caused by additional factors outside of or in addition to increases in overall star rating.

"The reputation premium": does hospital ranking improvement lead to a higher healthcare spending?

Global health systems have often disclosed hospital quality and performance information via hospital ranking or rating programs over the last 20 years. This study aims to examine the relationship between hospital ranking and healthcare spending. Using the Basic Medical Insurance claims data from a big city in central China and the hospital ranking data from the Fudan Chinese Hospital League Table from 2016 to 2018, this study exploits the variation of hospital reputable ranking across hospitals and periods to employ the difference-in-differences (DiD) design. To alleviate the self-selection bias emerging from inpatients' selection of hospitals and the extrapolation bias emerging from the potential mis-specification of our linear model, we combine the DiD design with the 3-to-1 optimal Mahalanobis metric matching method. This study finds that ceteris paribus one hospital ascending from the Regional Famous Hospital Group to the National Famous Hospital Group significantly increases inpatients' total healthcare costs, reimbursement costs, and out-of-pocket costs by 5.9%, 6.2%, and 4.0%, respectively. Mechanism analysis reveals that it should be attributed more to physician moral hazard than patient willingness-to-pay. Leads and lags (event study) analysis validates our DiD identification framework and shows that the impact materializes slowly but significantly. In the robustness check, we transfer the outcome variables from the log value to the level value and control five digits of ICD-10 for the disease fixed-effects. The results are highly robust.

Effects of Part D Star Ratings on racial and ethnic disparities in health care costs

Background

Racial/ethnic minorities are less likely than non-Hispanic White (White) patients to be included in the Medicare Part D Star Ratings measure assessment due to the restrictive inclusion criteria for the measures.

Objective

This paper examined the effects of racial/ethnic disparities in the measure assessment in Part D Star Ratings on disparities in healthcare costs among patients with Alzheimer's disease and related dementias (ADRD).

Methods

This cross-sectional study analyzed 2017 Medicare data. Proportions of Beneficiaries with ADRD were categorized into the included and excluded groups based on the inclusion criteria for the calculation of medication adherence measures in Star Ratings. Outcomes included costs for medications, physician visits, emergency room (ER) visits, and total costs. A generalized linear model was employed to compare costs across racial/ethnic groups. To explore the differential disparities in healthcare costs between the 2 groups, interaction terms between dummy variables for being excluded from the measure calculation and racial/ethnic minorities were included in the models.

Results

The patterns of racial/ethnic disparities in healthcare costs found in this study were generally consistent with expectations, with some exceptions. For example, compared with White patients, in the hyperlipidemia cohort, the physician visit cost for Black patients among the included group was 31% lower (cost ratio or CR = 0.69, 95% CI = 0.67-0.72); in the hypertension cohort, the hospitalization cost for Blacks among the excluded group was 15% higher (CR = 1.15, 95% CI = 1.12-1.19). More importantly, exclusion from measurement assessments was associated with differential cost disparities. For example, compared with individuals included in the measure assessment for hypertension, the Black-White disparities in costs for hospitalization and total healthcare were 30% higher (CR = 1.30, 95% CI = 1.26-1.34), and 10% higher (CR = 1.10; 95% CI = 1.08-1.12), respectively, among the excluded group.

Conclusions

Medicare Part D Star Ratings may be associated with aggravated racial/ethnic disparities in healthcare costs in the Medicare Part D population.

The impact of hospital price and quality transparency tools on healthcare spending: a systematic review

BACKGROUND

Global spending on health was continuing to rise over the past 20 years. To reduce the growth rates, alleviate information asymmetry, and improve the efficiency of healthcare markets, global health systems have initiated price and quality transparency tools in the hospital industry in the last two decades. OBJECTIVE : The objective of this review is to synthesize whether, to what extent, and how hospital price and quality transparency tools affected 1) the price of healthcare procedures and services, 2) the payments of consumers, and 3) the premium of health insurance plans bonding with hospital networks.

METHODS

A literature search of EMBASE, Web of Science, Econlit, Scopus, Pubmed, CINAHL, and PsychINFO was conducted, from inception to Oct 31, 2021. Reference lists and tracked citations of retrieved articles were hand-searched. Study characteristics were extracted, and included studies were scored through a risk of bias assessment framework. This systematic review was reported according to the PRISMA guidelines and registered in PROSPERO with registration No. CRD42022319070.

RESULTS

Of 2157 records identified, 18 studies met the inclusion criteria. Near 40 percent of studies focused on hospital quality transparency tools, and more than 90 percent of studies were from the US. Hospital price transparency reduced the price of laboratory and imaging tests except for office-visit services. Hospital quality transparency declined the level or growth rates of healthcare spending, while it adversely and significantly raised the price of healthcare services and consumers' payment in higher-ranked or rated facilities, which was referred to as the reputation premium in the healthcare industry. Hospital quality transparency not only leveraged private insurers bonding with a higher-rated hospital network to increase premiums, but also induced their anticipated pricing behaviors.

CONCLUSION

Hospital price and quality transparency was not effective as expected. Future research should explore the understudied consequences of hospital quality transparency programs, such as the reputation/rating premium and its policy intervention.

Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions

BACKGROUND

Enrollment in high-quality Medicare Advantage (MA) plans, measured by a 5-star quality rating system, was lower among racial and ethnic minority enrollees than White enrollees partly due to fewer high-quality plans available in their counties of residence. This may contribute to racial and ethnic disparities in ambulatory care sensitive condition (ACSC) hospitalizations.

OBJECTIVE

We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating.

METHODS

Using the Medicare enrollment and claims data for 2016, we identified White, Black, Hispanic, and Asian/Pacific Islander enrollees in MA plans. We estimated racial and ethnic disparities in ACSC hospitalizations (per 10,000 enrollees) overall and by star rating.

RESULTS

We found that the adjusted rates of ACSC hospitalizations were significantly higher among Black enrollees than White enrollees overall [39.4 (95% confidence interval: 36.3-42.5)]. However, no significant disparities were found among Hispanic and Asian/Pacific Islander enrollees. The adjusted rates of ACSC hospitalizations were higher in lower-rated plans than higher-rated plans in all racial and ethnic groups. The significant disparities in ACSC hospitalizations by star rating were the most pronounced between White and Black enrollees. We found suggestive evidence that enrollment in lower-rated plans was associated with higher disparities in ACSC hospitalizations between White and Black enrollees.

CONCLUSIONS

Substantial disparities in ACSC hospitalizations exist between White and Black enrollees in MA plans, especially for lower-rated plans. Policies aimed at reducing racial disparities in ACSC hospitalizations could include improving access to high-rated plans.

The Rise of Medicare Advantage: Effects on Total Joint Arthroplasty Patient Care and Research

BACKGROUND

Medicare Advantage (MA) plans are popular among Medicare-eligible patients, but little is known about MA in lower-extremity total joint arthroplasty (TJA). The purpose of this study was to describe trends in MA utilization and analyze differences in patient characteristics and postoperative outcomes between patients undergoing primary TJA using traditional Medicare (TM) or MA plans.

METHODS

Patients ≥65 years of age who underwent primary total knee or total hip arthroplasty were identified using the Premier Healthcare Database. Patients were categorized into TM and MA cohorts. Data from 2004 to 2020 were used to describe trends in insurance coverage. Data from 2015 to 2020 were used to identify differences in patient characteristics and postoperative complications using ICD-10 codes. Multivariate analyses were performed using 2015 to 2020 data to account for potential confounders.

RESULTS

From 2004 to 2020, the proportion of patients with MA increased from 7.9% to 34.4%, while those with TM decreased from 83.7% to 54.0%. Of the 697,317 patients who underwent primary elective TJA from 2015 to 2020, 471,439 (67.6%) had TM coverage and 225,878 (32.4%) had MA coverage. The cohorts were similar in terms of age and sex. However, a higher proportion of Black patients (8.29% compared with 4.62%; p < 0.001) and a lower proportion of White patients (84.0% compared with 89.2%; p < 0.001) were enrolled in MA compared with TM. After controlling for confounders, patients with MA had higher odds of surgical site infection (adjusted odds ratio [aOR]: 1.15; 95% confidence interval [CI]: 1.04 to 1.47; p = 0.031), periprosthetic joint infection (aOR: 1.10; 95% CI: 1.03 to 1.18; p = 0.006), stroke (aOR: 1.15; 95% CI: 1.02 to 1.31; p = 0.026), and acute kidney injury (aOR: 1.08; 95% CI: 1.04 to 1.11; p < 0.001), but lower odds of urinary tract infection (aOR: 0.94; 95% CI: 0.90 to 0.98; p = 0.003).

CONCLUSIONS

From 2004 to 2020, the number of patients utilizing MA increased markedly such that 1 in 3 were covered by MA in 2020. From 2015 to 2020, patients who were non-White were more likely to have MA than TM, and the MA group had a higher rate of several postoperative complications compared with the TM group. As TM claims data inform health-care policy and clinical decisions, this change portends future challenges, including limitations in arthroplasty registry research, an increase in the administrative burden of surgeons, and a potential worsening of social disparities in health care.

Association of Health Insurance Literacy With Enrollment in Traditional Medicare, Medicare Advantage, and Plan Characteristics Within Medicare Advantage

IMPORTANCE

Health insurance literacy helps individuals make informed choices. However, evidence suggests that Medicare beneficiaries experience low health insurance literacy, leading to high-cost or poor-quality coverage choices.

OBJECTIVE

To examine how health insurance literacy was associated with coverage choices between traditional Medicare (TM) and Medicare Advantage (MA), as well as within MA.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 6627 TM and MA enrollees, using data from the 2015-2016 Medicare Current Beneficiary Survey. Data analyses were conducted between May 1 and June 30, 2021.

EXPOSURES

Three self-reported measures of health insurance literacy (presence of information to make an informed comparison, ease in reviewing and comparing coverage options, and annual review and comparison of coverage options).

MAIN OUTCOMES AND MEASURES

Enrollment in TM vs MA and enrollment in an MA plan with different characteristics (star rating, monthly plan premium, in-network maximum out-of-pocket limit, plan type, and provision of supplemental benefits).

RESULTS

We included 6627 Medicare beneficiaries (3578 women [54.0%]; mean [SD] age, 75.13 [7.12] years). A total of 77 individuals were Asian (1.2%), 696 were Black (10.5%), 488 were Hispanic (7.4%), 5277 were non-Hispanic White (79.6%), and 225 (3.4%) were single races not of Hispanic origin (including American Indian or Alaska Native and Native Hawaiian) or were 2 or more races. Medicare Advantage enrollment was higher among individuals with higher health insurance literacy than those with lower health insurance literacy, especially for those who reviewed or compared coverage options annually than among those who did not (38.0%; 95% CI, 36.0%-40.1% vs 27.8%; 95% CI, 25.8%-29.7%). Among MA beneficiaries, those who reviewed or compared coverage options annually were more likely to enroll in plans with 4 to 4.5 stars and plans with monthly premiums of $1 to $50 by 4.6 percentage points (95% CI, 0.1-9.2 percentage points) and 4.8 percentage points (95% CI, 0.6-9.0 percentage points), respectively. However, enrollment in plans with 5 stars was 3.8 percentage points lower (95% CI, -5.8 to -1.9 percentage points) among individuals who reviewed or compared coverage options annually than among those who did not. Among individuals with low socioeconomic status, the likelihood of reviewing or comparing coverage options annually was lower for those with Medicare and Medicaid dual eligibility than for those without it (odds ratio, 0.79; 95% CI, 0.63-0.99).

CONCLUSIONS AND RELEVANCE

Results of this study suggest that higher health insurance literacy-particularly, annual review and comparison of coverage choices-is associated with higher MA enrollment and choice of a particular MA plan. Policy makers should develop programs to encourage frequent review and comparison of coverage options for informed decision making.

Association of Public Reporting of Medicare Dialysis Facility Quality Ratings With Access to Kidney Transplantation

IMPORTANCE

Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known.

OBJECTIVE

To determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged ≥18 years) patients in the US Renal Data System beginning long-term dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021.

EXPOSURES

Dialysis center quality, as defined by Medicare DFC star ratings.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics.

RESULTS

Of 507 581 patients beginning long-term dialysis in the US from 2013 to 2017, 291 802 (57.4%) were male, 266 517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively.

CONCLUSIONS AND RELEVANCE

In this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.