NOTE: This blog is co-published in collaboration with Lilac Software. Learn more about Lilac’s Stars Analytics and Agentic AI solutions at https://lilacsoftware.com.
A transparency scorecard could be adopted over time as a parallel initiative to promote better accountability
Back on February 5, I did a blog that covered changes in the Medicare Advantage Star program and how things may transform even more. I covered the major changes in the Trump administration’s proposal to eliminate operational or administrative measures; proposals congressional policy arm MedPAC has made over the years; and a January 22 Health Affairs Forefront blog where a former Centers for Medicare and Medicaid Services (CMS) innovation official (Liz Fowler) and colleagues outlined their proposals for reform of Star. I noted that the influential Paragon Health Institute has also proposed some additional radical changes. See that detailed blog here: https://www.healthcarelabyrinth.com/could-even-more-medicare-advantage-star-changes-be-around-the-corner/ .
In addition to endorsing the retirement of the administrative measures as part of Stars proper, Fowler and her colleagues recommended that policy makers increase transparency via a Medicare Advantage Transparency Scorecard (MATS). They said prior authorization (PA), provider payment patterns, encounter data completeness, marketing activities, corporate stewardship, and health equity all could be included but may not need to be rated in Stars.
The scorecard details
Fowler and team have now come back to explain the MATS transparency scorecard in a February 10 Forefront blog.
They articulate that while the elimination of the operational measures from Stars itself make sense, it opens up another challenge. Operational issues matter to beneficiaries, providers, and policy makers and are indeed central to the performance and accountability of the MA program. They say a distinct transparency tool designed for oversight, learning, and accountability rather than financial incentives should be adopted. The scorecard would increase visibility into practices and performance across key non-clinical domains.
The team says the scorecard would not be a “beneficiary-facing plan selection tool, would not be tied to bonus payments, and would not function as a formal regulatory enforcement mechanism.”
The blog articulates that CMS, policy makers, researchers, and the public would have “a structured, standardized way to assess how MA plans operate—and how those operations affect beneficiaries, providers, and the Medicare program.” Measurement could be refined over time and would focus on transparency of a range of issues rather than composite scoring or rankings. They say the tool would call out variation and outliers.
Fowler et al. propose five domains, which could be reported at the contract, plan or corporate levels depending on the subject matter area:
- Patient Access to Care: Utilization management, prior authorization, network adequacy, appeals and overturn rates, and beneficiary out-of-pocket exposure.
- Payment Integrity and Provider Relationships: Claims denials, appeals, medical loss ratios, and other payment practices tied to delivery of care.
- Compliance and Marketing: Complaints, enforcement actions, disenrollment rates, data completeness, and marketing practices.
- Corporate Social Responsibility: Market concentration, margins, and corporate practices.
- Health Equity: Serving dually eligible beneficiaries, low-income enrollees, rural populations, and other groups facing structural barriers. This could fill the void left by the proposed elimination of the Excellent Health Outcomes for All (EHO4all or Health Equity Index reward) in Stars.
The link to the blog is at the end of this blog. Fowler and team do a great job of providing details of the scorecard, including specific metrics to be included in each domain and the available data sources for measurement.
Is CMS looking at something like this and does it make sense?
I have to think so. The Biden administration’s CMS, Trump’s CMS, and Capitol Hill in general have been very concerned about various issues relating to MA operations:
- While I disagree with many of the reforms made on the PA front (I think they take the managed care out of managed care), the prevailing wisdom has been that MA plans’ approaches here have gone too far. Fair criticism has been leveled against the lack of transparency of authorization criteria, knowledge of appeals processes, and the small percentage of members that appeal initial denials. Some reforms are being implemented here.
- Claims practices have been criticized for the processing time, documentation needed, and denial rates. Providers have convinced Capitol Hill and CMS that the practices erode revenue and impact cash flow.
- Risk adjustment practices at least at a subset of plans have been aggressive if not fraudulent.
- Similarly, marketing and enrollment approaches among a subset of plans border on fraudulent if they haven’t crossed the line.
It is also true that much of this data is already being collected by CMS via annual reporting and during program audits. The problem is that it is not made available to the public in a clear and concise fashion if at all.
Does a Stars reward program with a transparency scorecard make sense? I think it does. The Stars program would hold plans accountable for measurable and targeted quality improvements and achievement, while the transparency scorecard makes clear to CMS and the public how plans are performing operationally in terms of member experience, fairness, equity, and efficiency. Accountability could be promoted with a reformed Stars program and a comprehensive MA Transparency Scorecard on non-clinical dimensions.
While Fowler and Team’s proposal is a good one, I somewhat disagree that it should not be beneficiary-facing or be an enforcement tool. I would argue that the transparency scorecard, if simple enough, would give the public a better understanding of how well plans operate on these important areas. And as important as these issues are, why not use it to penalize poor performers and terminate bad players. It could become an adjunct to and inform program audit activities.
Yes, it might be more work for plans and CMS, but with the Medicare trust fund near insolvency, the public deserves an accountable program that improves healthcare quality, reduces costs, and promotes efficiency. A twin refined Stars program focused on quality and a transparency scorecard might well calm the current waves and align everyone – the public, CMS, and lawmakers – on the unique value that is MA. And as Fowler et al. note, the scorecard idea could be rolled out and have iterations over time.
While plans might say the scorecard is too much, it should be noted that CMS’ accountability initiatives in the past have built trust in MA from the public’s perspective and that has led to surges in MA’s popularity and enrollment.
Health Affairs Forefront blog: https://www.healthaffairs.org/content/forefront/beyond-star-ratings-proposal-medicare-advantage-transparency-scorecard
#medicareadvantage #stars #quality #cms
— Marc S. Ryan
