Medicare's star ratings help you decide, but aren't simple

It's one of television's most persistent commercials: A vital, chatty, white-haired guy brags to his adult daughter about saving a bundle on a terrific Medicare health plan.

But if the actor who plays the role really was a Universal Health Care customer, he would have received a disturbing letter recently from the federal government. Medicare has rated the company's performance either "poor" or "below average" for three years running.

"We encourage you to compare this plan to other options in your area and decide if it is still the right choice for you,'' said the letter.

Ratings, advisories and bonuses are part of Medicare's push to improve quality of care, not just pay the bills.

Medicare Advantage plans, run by insurers, earn companies hundreds of dollars a month for each person they sign up. The government wants to make sure they don't skimp on care.

The rating system — from 1 to 5 stars — started five years ago and can be found on Medicare's online Plan Finder. A red "warning" label is affixed to any plan that earns less than 3 stars for drug or health benefits for three years running.

That's what happened to Universal, a St. Petersburg-based company with thousands of clients in the Tampa Bay area.

The scores were "below our expectations,'' vice president Richard Pilon acknowledged in a statement. The company "would like to assure our members and partners that we are working diligently to improve our scores.''

• • •

The big ratings winner was Humana's Gold Plus HMO, which earned 4.5 stars, the first Florida plan to score that high.

Humana is the state's biggest purveyor of Medicare plans, with about 320,000 members just in Gold Plus. When the Affordable Care Act set up financial incentives for quality four years ago, Humana launched a company-wide campaign to raise its scores, said Scott Latimer, marketing president for Central Florida.

Among other steps, Humana appointed a "star czar,'' a nurse whose sole job was to educate employees throughout the company on how their actions would affect the rating, which is based on 54 separate components. Most are clinical factors, like controlling blood pressure. But customer service matters, too.

Humana also started paying a bonus to doctors for treating patients in ways that please Medicare and for keeping proper documentation that Humana could submit to the government.

Did the patient get an annual flu shot, cholesterol screening and mammogram? Are medications reviewed every year?

Humana shelled out about $34 million in bonuses to doctors statewide, Latimer said.

Some rating components depend on patient behavior. So Humana gave them small gifts, like a towel or water bottle, for getting certain tests.

"It was not huge,'' Latimer said. "But on the other hand, one of the challenges is that many people will say, 'I feel healthy. I don't need a screening test.' We can't make them do the right thing.''

By earning 4.5 stars, Humana will collect a 5 percent bonus for 2012. With Medicare paying plans an average of about $800 per month, per client, that should earn Humana something like $160 million.

• • •

How much the star system affects consumer choices remains to be seen. Studies show that most Medicare beneficiaries simply keep coverage with the same plan from year to year.

Charles Franckle is Pinellas County coordinator for Florida's SHINE program, which helps older and disabled people with Medicare questions. Few callers ask about the star system, Franckle said, though SHINE did field a flurry of calls when Universal members received Medicare's cautionary letter last month.

"Some said, 'Do I have to change?' '' Franckle said. Callers were told there was no need to change if they were happy with their doctor and service. Many factors, not just stars, should go into a decision, he said.

Humana has been advertising its top rating for a few weeks. Latimer couldn't quantify whether that has translated into more business — people have until Dec. 7 to choose a plan for next year.

"But we have seen a significant uptick in phone calls,'' he said, "and people are scheduling appointments.''

• • •

The pot of gold is that fifth star. A few plans around the country have earned it, but none in Florida.

Plans typically can advertise to and enroll existing Medicare beneficiaries only during an "open enrollment" window that runs from mid October until early December. Under the Affordable Care Act, five-star plans can advertise and enroll all year — a huge marketing advantage.

Imagine if everybody dissatisfied with their plan at any point during the year could switch immediately to a competitor.

"We are committed to getting to five stars,'' Latimer said.

A few components of the rating offer some targets. Humana scored only 2 of 5 stars for "improving or maintaining mental health,'' and "monitoring physical activity.''

Another 2-star category, "rheumatoid arthritis management,'' can present a problem, Latimer said. Medicare bases its rating on use of a particular prescription drug that not all doctors like. "At the end of the day, the doctor has the final say,'' Latimer said.

The 2012 star ratings held some surprises.

Optimum Healthcare, a small Tampa-based company that offers some of the area's least expensive plans, earned an impressive 4 stars.

AARP plans, run by UnitedHealthcare, are popular among Floridians, but earned only 3 stars for the second year. That's just a little above Universal's 2.5 ratings.

Universal's scores show how varied the separate components of the overall rating can be.

The Universal Masterpiece HMO scored 1 out of 5 on fairness of drug coverage denials, but 5 out of 5 for fairness of health coverage denials.

The plan scored 1 of 5 on administering flu vaccines, controlling blood pressure and weight control, but 5 of 5 on "improving or maintaining physical health.''

The company is adding an executive team to improve its rating by next June, Polin said. But much depends on clients, he said, noting the effort includes "educating our members on the importance of preventative care and medication adherence.''

Contact Steve Nohlgren at nohlgren@tampabay.com

Seeing stars

Here are Medicare's overall ratings for health plans offered in the Tampa Bay area that provide drug coverage. (Special needs plans, prescription drug plans and plans too new to be rated are not included.)

4.5 stars: Humana Gold Plus

4 stars: Optimum Gold Rewards, Optimum Platinum, Preferred Secure Option

3.5 stars: Aetna Medicare Premier, Aetna Medicare Value, CareFree, CareOne, CareOne PLUS, Freedom Medicare Rx, Freedom Savings RX, Humana Gold Choice, Humana Reader's Digest Healthy Living, Humana Choice.

3 stars: AARP MedicareComplete, AARP MedicareComplete Choice, AARP Medicare Complete Choice Plan 2, BlueMedicare HMO and PPO plans, Coventry Advantra Ideal, Coventry Advantra Select Plus, PUP Plus, PUP Simple, WellCare Dividend, WellCare Essential, WellCare Value

2.5 stars: Amerivantage Classic + Rx, Universal Masterpiece, Universal Masterpiece Plus, Universal Safeguard

2 stars: Universal Any, Any, Any

Source: Centers for Medicare and Medicaid Services, Plan Finder, at medicare.gov

Medicare's star ratings help you decide, but aren't simple 11/22/12 [Last modified: Thursday, November 22, 2012 9:33pm]

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