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PCPs central to star ratings


With the Medicare star program, plans stand to gain bonus pay when their network providers do well on performance measures

Medicare Advantage plans have a huge stake in the quality of care that primary care physicians (PCPs) deliver. With the Medicare star program, plans stand to gain bonus pay when their network providers do well on performance measures.

Plans must ensure their primary care physicians have the resources to take better care of their patient populations. Physicians need actionable patient information, decision support, analytics and, in some cases, even personnel support. And the stakes couldn’t be higher.

A study published in January in the Journal of the American Medical Association showed a strong link between a plan’s Medicare star rating and the likelihood for enrollees to choose that plan. A one-star difference among plans made first-time enrollees nearly 10% more likely to choose the higher-rated plan. For current enrollees who were switching plans, a one-star difference was linked to a 4.4% greater chance of picking that plan.

Plan geography, integration matter

Higher-rated plans tend to be concentrated where plans have a strong local market presence, a tightly integrated model or both characteristics, says Greg Scott, principal and national leader of health plan consulting at Deloitte Consulting LLP.

“In plans with a larger geographic footprint, there might not be enough members in a physician’s panel of patients for the plan to exert much influence,” Scott says.

Health plans can influence physician behavior through financial incentives, integrated health records and real-time or near real-time data comparing the physician or practice against performance targets or peer groups, he says. But even the best programs have their practical limitations. When interacting with patients, Scott believes physicians aim for optimal care for each individual patient, not satisfying a payer program requirement.

With more payer programs coming onboard, physicians are concerned about administrative burdens.

The average provider has 10.5 payer relationships, according to Jason Rose, senior vice president of business development at Inovalon, a data analytics company. What physician wouldn’t buckle under 10 information portals, 10 sets of patient data and 10 sets of quality measures? Even with data support, health plans must walk a fine line between informing their network PCPs and overwhelming them with too much data.

Many observers believe private market plans and public plans should agree on common sets of quality measures to reduce the reporting burden on physician practices.

Kristian Marquez, vice president of clinical and quality outcomes at Inovalon, notes that quality improvement in general can be complex, but he also believes that successful plans share common characteristics. They include best-in-class modalities and a thorough understanding of how much the organization can leverage its data to drive quality outcomes. Data can be used in identifying high-performing providers as well as those who might need additional decision support.

Integrated systems don’t necessarily have an easier time influencing quality among PCPs.

The highly integrated UPMC Health Plan has 115,000 enrollees in its Medicare and dual-eligible plans in Pennsylvania and West Virginia. However, only 40% of its physicians are employed by the system, says Stephen Perkins, MD, vice president of medical affairs. The employed and the network physicians must be onboard with quality programs.

“To be successful, you have to establish credibility with the physician,” says Eugene Scanzera, vice president, Medicare for UPMC. “They need to understand what we bring and how we can enhance the practice. We don’t insert ourselves between the patient and the physician.”

For UPMC, establishing credibility includes sharing information on star and HEDIS measures, comparing practices in terms of care quality and offering quality-based incentives through pay-for-performance measurements.

“We don’t look at isolated metrics,” Dr. Perkins says. “We look at metrics in total. We look at Centers for Medicare and Medicaid Services guidelines, star and others we feel are important in fulfilling the Triple Aim. For example, access to physicians is not a star measure, but it’s something we track.”

Access can come indirectly through the health plan call center, for example, where staff might help members review which preventive screenings they need and transfer the call to the appropriate scheduler to make an appointment, says Colleen Walsh, senior director of quality improvement at UPMC. Support can include a nurse practitioner liaison for each practice who can help physicians and staff achieve quality metrics, such as delivering appropriate preventive measures.

Differences in geriatric care

SCAN Health Plan focuses much of its efforts on educating its providers on how to interview, examine and address geriatric patients, says Romilla Batra, MD, vice president and medical director of the Medicare Advantage plan with 144,000 members in California and Arizona. 

“Our mission is very geriatric-focused. We home in on the skills needed to engage this population and pass them along to our PCPs,” says Dr. Batra. “Not many physicians have a geriatric specialty.”

The plan engages its physicians through short podcasts on relevant issues; regional conferences where physicians can earn continuing education credits on such topics as motivational interviewing and geriatric physical exams; and practice support. Information includes how primary care offices can be designed around senior patient needs and how physicians and staff should contact and address older people.

For example, one 20 minute online course outlines the basic model of the Special Needs Plan and the provider responsibilities. Also on SCAN’s provider portal is a toolkit to help physicians communicate with patients of various ethnic cultures.

“Our patients like to be called-no email, no postcards,” Dr. Batra says. “There is a small segment that is tech savvy, and we communicate with them in the way they want.”

SCAN offers quality bonuses to providers who encourage health screenings, run efficient practices, and use evidence-based and age-based practices.

Plans also must recognize that many patients might choose a specialist as their primary care physician, says Bill MacBain, senior vice president at Gorman Health Group, a consulting firm that works with Medicare Advantage plans.

“For those with diabetes, the endocrinologist might be the PCP,” MacBain says. “For patients with arthritis, it may be the rheumatologist, and for those with kidney problems, it may be the nephrologist. Regardless of the perceived primary care physician, the health plans have the 360-degree view of what’s happening with patients, the information resources and the monetary resources to bring change.”

The largest stumbling block to quality feedback remains interoperability among information databases, MacBain says, a situation that is slowly changing. Even physicians that aren’t integrated must be able to share patient data to achieve quality outcomes.

Batra believes the Medicare star ratings are aligning reimbursement and quality in unprecedented ways. But Perkins from UPMC describes the system as ever-evolving.

“It’s core purpose is strong-to improve patient outcomes,” Dr. Perkins says. “The challenge for health plans is to adapt to the changes in methodology so we can measure ourselves and keep ahead of the curve.”

Even health plans not engaged in Medicare Advantage may soon find themselves in the rating game. The Department of Health and Human Services is creating a program similar to the Medicare Advantage star rating program for the exchange market, notes Rose. The patient Protection and Affordable Care Act also directs the secretary of HHS to develop and administer an enrollee satisfaction survey system, the results of which will be available to exchange consumers.

States also can develop their own quality program, an avenue that six states have taken.

At its core, medicine is a cottage industry. For those who are frail or have chronic conditions, a large number of physicians, specialists, pharmacists, therapists, home health workers, counselors and others may be involved in one patient’s care.

Regardless of the payment model, care model or quality methodology, Scott from Deloitte notes that physicians will be at the core of any effort to improve patient outcomes.

“Plans have to pay attention to how individual physicians react, because not all [models] will work out as hoped,” he says. “The industry will have to sort through the noise to determine what works, how, when, why and how to replicate the successful ones.”

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