Quality, Schmuality: Rating the (Medicare Plan) Stars

As Medicare open enrollment gets underway this month, what should reporters make of the latest announcement about the new star ratings for Medicare Advantage (MA) plans - the kind that more and more seniors are choosing to fill in the holes in Medicare's coverage?

The stars indicate how well a plan takes care of its members with certain health conditions, the quality of its customer service, and responsiveness to customer complaints.  

It's tempting to write the bread-and-butter story saying that Medicare has a new tool to help consumers choose a better plan. That's the one Medicare would like us to write and so would sellers of MA plans that got high marks. Or we can write a story about whether consumers should use them at all because other aspects of a plan are more important to people on Medicare.

I would opt for a little of both, but I would not suggest consumers should pin their shopping decisions on the stars.  The rating system isn't ready for that.  

One actuary who helps insurers figure out what to charge for their Medicare Advantage plans says: "the ratings are better than a poke in the eye with a sharp stick. A lot of the measures are soft. And some measure things a plan has no control over." 

He says the star system penalizes plans with doctors who are notoriously uncooperative when it comes to measuring plan performance and plans with noncompliant patients, such as diabetics who don't come in for their foot exams.

Yet there are important take-aways buried in the Medicare announcement that only nine plans offered by four different sellers received a five-star rating. Reporters might consider digging out these nuggets and using them to craft stories this fall.

Almost all the top plans are run by not-for profit insurers, which are becoming scarce in an industry that is now mostly controlled by five mega-for-profit companies. Surprise, surprise! 

The not-for-profits appear to do a better job of caring for their members and giving them help when they have a question. Martin's Point Generations Health Care in Maine is one of those not-for-profits. I talked to the health plan's CEO Dr. David Howes, who described his plan's emphasis on primary care and some of the success his organization has had in getting patients to comply with treatment regiments and getting doctors to do the right thing. He told me that because there were no shareholders to satisfy, the plan can focus on a commitment to good care.

Most seniors who choose MA plans, however, do not have a choice of a five-star plan sold by not-for-profit insurers. They don't even have a choice of four-star plans. Two-thirds are in mediocre average plans that have received two and a half, three, or three and half stars run largely by for-profit companies.

The star system may be as much a way to give insurers back some of the money the health reform law took away as it is about pushing for better care. Recall that Congress reduced the overpayments to the plans and redirected the money to pay for subsidies for the uninsured come 2014. Despite their average showing of so many plans, the government is giving them bonus payments.  That's right - a bonus for being average. Four and five star plans get a five percent bonus payment from the government while plans with three star plans get a three percent bonus. You might call it government schizophrenia.

While the measures are far from perfect indicators of high quality care, they do seem to tell us one thing - care is not top-notch for almost all of the quality measures, particularly for some that are of interest to older people. For example, the average star rating for improving bladder control is only 1.83 stars; pain screening 2.72; improving or maintaining mental health 2.15; and managing women who have had a fracture 2.06. When it came to monitoring physical activity, a key determinant of health for the elderly, the average star rating was only 1.91. Are plans really concerned about that?  

So much for the larger picture! Is there anything that consumers themselves can learn from the stars that might help with their decisions during open enrollment this fall?  

Price and whether your physicians are in the plan's network still trump other considerations and they probably should, given how tight senior's budgets are.

But all things being equal or close to equal, a plan that does better on customer service and handling members' complaints might be the better choice. No consumer wants to spend hours on the phone so a plan with four stars on this measure is better than one with two or three.

A good story for journalists this open enrollment season is to sit down with a senior and go through the decision-making process with them. It is not as simple as reaching for the highest stars. It is much harder than any Washington bureaucrat imagines.

Medicare open enrollment for 2012 closes December 7, 2011.

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She is a long-time contributing editor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security, and retirement.