Very poor, very sick elderly do
worse in Medicare programs due to circumstances
by Medicare-Medicaid insurers say CMS cannot expect same healthcare
results as for those from better environments
By Tucker Sutherland,
1, 2015 – If you are very, very poor and very, very sick – as are most
Americans known as “dual eligibles” by the Centers for Medicare &
Medicaid Services – you are likely to fair worse than others being
treated with the same level of care by Medicare healthcare providers.
This is the conclusion from a study funded by a healthcare technology
company and the Special Needs Plan (SNP)
group of companies that offer Medicare-Medicaid insurance plans.
release issued by the technology firm, Inovalon, says this was the largest analysis ever performed on dual
eligible quality outcomes. Dual eligibles are people who have been
qualified by the CMS as being entitled to services under both Medicare,
which is generally for all Americans age 65 and older, and Medicaid,
which is for those with very low incomes.
The study analysis said the dual
eligibles “have worse health outcomes that cannot be attributed to a
health plan’s quality of service. Moreover, additional factors beyond
the high-risk chronic health conditions that members present may
contribute to worse health outcomes.”
The study findings also “indicate
that Medicare Advantage (MA) plans serving disadvantaged beneficiaries
may provide higher-quality care than their ratings reflect under the
current Five-Star Rating System Medicare uses to assess the performance
of plans. This is the first large-scale, independent study to
investigate health outcomes of Medicare beneficiaries enrolled in MA
plans at the member-level.”
Christie Teigland, Ph.D., senior
director of statistical research at Inovalon and principal investigator
of the study, said, “This is an important, ground-breaking analysis of
data not previously achievable in the industry.”
“The results show that a higher
prevalence in the dual eligible population of high-risk clinical
conditions, sociodemographic factors such as living in a high poverty
area, and community resource factors such as living in an area with a
shortage of primary care physicians, result in worse outcomes given the
same access and quality of care.”
“The study provides compelling
evidence that quality measures in the Five-Star Rating System do not
fully capture the complexity of the circumstances in which Medicare’s
dual eligible population lives or the complexities involved in their
health care,” said Richard Bringewatt, president and chair, SNP
“Performance measures must take
this evidence into account for health plans to have an accurate quality
rating system. Plans and providers that serve disadvantaged populations,
such as MA Special Needs Plans, should also take this evidence into
account as it sheds light on a range of sociodemographic factors that,
if properly addressed, could help us develop and target more ways to
improve health outcomes for our members.”
“We’ve suspected all along that the
poorer health outcomes of dual eligible members are not caused by the
quality of plans, but are due to other factors,” said Dr. Paige
Reichert, medical senior director of quality, Cigna HealthSpring.
“If the disparity of outcomes
between dual eligible and non-dual eligible members were due to the
quality of care provided by the plan, the results would have been
similar between both groups. However, because the study controlled for
similar member characteristics, we see that it is sociodemographic
factors that are affecting health outcomes. Clearly the issues that are
affecting the health outcomes of disadvantaged beneficiaries need to be
addressed to eliminate health disparities, and should also be taken into
account when measuring the quality of Medicare managed care plans.”
The news release said, “Insights
gained from this analysis will empower new advancements in Inovalon’s
patient-level and provider-level analyses technologies designed to
achieve greater insight into the identification of gaps in care,
quality, and financial performance, as well as the intervention
platforms needed to resolve such gaps.”
Inovalon conducted this research in
collaboration with Cigna-HealthSpring, WellCare, Healthfirst, Gateway
Health, BCBS Minnesota and Blue Plus, Health Care Service Corporation (HCSC),
the Special Needs Plan (SNP) Alliance, and Medicaid Health Plans of
America (MHPA), and consulted with multiple other industry partners.
For its research, Inovalon says it
used member-level Medicare Advantage data from a number of collaborating
health plans and de-identified data extracted from its Medical Outcomes
Research for Effectiveness and Economics Registry (MORE2
Registry®), one of the industry’s largest healthcare
datasets. These datasets were combined with additional sources,
including CMS Monthly Membership Reports, U.S. Census data, and detailed
data on sociodemographic and community resource availability. The study
evaluated performance on 18 Five-Star quality measures for more than 2.2
million Medicare Advantage members, drawn from 81 separate Medicare
Advantage contracts comprising 364 individual health plans.
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