The Med Diva

Medicare’s moving parts, Part 1: Three strikes you’re out

I often tell people that Medicare is a cluster a moving parts: the parts being A, B, C, D, and so on; the “movement” generated by annual regulatory changes courtesy of the Centers for Medicare & Medicaid Services (CMS). Although these regulations provide job security for many people, they also greatly add to the confusion for Medicare providers, pharmacists, plan sponsors, and of course, beneficiaries.
 
For example, in October, CMS issued Federal Register Volume 76, Number 196, which addresses proposed changes to the Medicare Advantage and Medicare Prescription Drug Benefit programs for 2013. This 161-page, 77,017-word document, with all its sections and sub-sections, is absolutely mind-boggling. Feel free to take a peak here, but don’t say I didn’t warn you!

In my next few blogs, I’m going to try to break it all down and explain some of the points that may be of interest to you and other Medicare beneficiaries.

I want to start, however, by confessing that I’m getting a lot of help from the Medicare Rights Center, a national, nonprofit consumer service organization that works to ensure access to affordable, high-quality health care for Medicare beneficiaries. Click here to check out their excellent e-mail newsletters.

Today I’m going to briefly discuss sections (§) 422.504, 422.510, 423.505, and 423.509, which are grouped together and titled, “Plan Performance Ratings as a Measure of Administrative and Management Arrangements and as a Basis for Termination or Non-Renewal of a Medicare Contract.”  Under this guidance, Medicare Advantage (Part C) and Medicare prescription drug (Part D) plans that receive a summary star rating of less than three stars for three years in a row would be subject to termination.

The proposed ruling states, “A summary rating of less than 3 stars can be achieved only when a sponsor demonstrates poor performance across a range of measures. Therefore, we believe that sponsors that consistently achieve poor plan ratings have demonstrated a substantial failure to comply with the terms of their Medicare contracts.” CMS further states that it believes three years is enough time for a sponsor to develop and put in place corrective action.

In response to this proposed regulation, the Medicare Rights Center states that while it agrees plans with low star ratings should be terminated, three years is too long to allow poor performers to stay in business serving Medicare beneficiaries. “Keeping a low quality plan in the market for three years seems inappropriate and dangerous for beneficiaries,” the center notes in its comments to CMS.

The center also believes that if plans have a one- or two-star rating in any one year, CMS should strengthen incentives for plans to improve quality immediately and better protect beneficiaries. And it recommends CMS consider the use of sanctions or other enforcement mechanisms if a plan’s rating consistently fluctuates between one to three stars; then once a plan with one or two stars improves to three stars, a probationary period should kick in for that plan to ensure it continues to meet adequate performance goals.

I agree that three consecutive years of poor performance is not acceptable. As the writer for a national prescription drug plan that received 5 stars in 2010 and 4 in 2011 (the highest ratings of any national plans in the country), I know first-hand how difficult it is to achieve and maintain a high star rating. But it makes me feel good to know that everyone I work with is taking those extra steps to ensure our members get the service they need to stay healthy and safe. There’s no reason for any plan to continue serving beneficiaries if it can’t achieve a 3-star rating or better in any one year.