Medicare Star Ratings Don’t Reflect Disparities in Quality of Care

Not only are Medicare Advantage (MA) star ratings not representative of quality of care for enrollees from racial/ethnic minorities and those with low socioeconomic status (SES)—but the higher the star rating, the wider the disparities in quality, according to results from a cross-sectional analysis.

Since 2008, the U.S. Centers for Medicare and Medicaid Services (CMS) have used a five-star rating scale to measure the performance of MA contracts, with annual bonus payments allocated to the contracts with the highest ratings, without stratification based on race, ethnicity, or SES, David J. Meyers, PhD, MPH, of the Department of Health Services, Policy, and Practice at Brown University School of Public Health in Providence, Rhode Island, and colleagues wrote in JAMA Health Forum.

The problem, they noted, is that previous research has shown that MA plans—which enroll higher proportions of racial/ethnic minorities and low-income individuals than traditional plans—have substantial disparities in care, both within and between plans. “If aggregate contract star ratings hide clinically important differences in quality between advantaged and disadvantaged plan members, then quality measures that directly assess equity maybe needed,” they argued.

Meyers and colleagues set out to determine whether there is an association between an MA contract’s overall star rating and what the star rating would look like if calculated specifically for enrollees of racial/ethnic minorities or low SES, as well as whether or not contracts with higher star ratings have lower disparities in care.

Their analysis uncovered four key findings, they wrote:

• “First, we observed only a modest correlation of simulated star ratings when calculated for enrollees of low SES and high SES, and between racial/ethnic minority enrollees and White enrollees in the same contract.
• “Second, contracts with higher star ratings had larger racial/ethnic disparities than did those with lower star ratings.
• “Third, the contracts with lower concentrations of individuals of low SES and Black or Hispanic individuals had larger disparities and worse quality for these individuals.
• “Fourth, we identified both within-plan and between-plan disparities in the quality of care in the MA program, as measured by the star ratings.”

“The study by Meyers and colleagues adds to the growing body of studies describing quality-performance disparities for individuals with greater burdens of social risk factors,” Cheryl L. Damberg, PhD, and Marc N. Elliott, PhD, of the RAND Corporation in Santa Monica, California, wrote in an invited commentary accompanying the study. “The authors found evidence of disparities in one of the largest quality-incentive programs in the United States, consistent with prior findings reported by Joynt and colleagues in 9 federal performance-based payment systems. The evidence prompts consideration of potential actions to address disparities in the context of performance accountability and value-based payment programs.”

For their analysis, Meyers and colleagues compiled individual-level data on 22 measures of quality and satisfaction included in CMS’ current star-rating calculation using four primary sources from the 2015/2016 calendar years—the Medicare Health Outcomes Survey (HOS); the MA Consumer Assessment of Healthcare Providers and Systems (CAHPS); MA Healthcare Effectiveness Data and Information Set; and the Master Beneficiary Summary File (MBSF). The study included 1,578,564 MA enrollees (55.8% female; mean [SD] age, 71.4 [11.3] years; 65.8% White; 12.3% Black; 14.6% Hispanic) from 454 contracts during the 2015 and 2016 calendar years.

The main exposures were self-reported race/ethnicity and low SES (defined as low income or less than a high school education) versus high SES (defined as neither low income nor low education); the main outcome was MA contract performance on the “22 measures of quality and satisfaction determined at the individual enrollee level, aggregated into simulated star ratings (scale, 2-5) stratified by SES and race/ethnicity,” they explained.

“Enrollees with low SES had simulated stratified star ratings 0.5 stars lower (95% CI, 0.4-0.6 stars) than individuals with high SES in the same contract. Black and Hispanic enrollees had simulated star ratings that were 0.3 stars (95% CI, 0.2-0.4 stars) and 0.1 stars (95% CI, −0.04 to 0.2 stars) lower than White enrollees within the same contracts,” Meyers and colleagues found. “Black enrollees had a 0.4-star lower rating (95% CI, 0.1-0.7 stars) in 4.5- to 5-star contracts and a no statistical difference in 2.0- to 2.5-star–rated contracts (difference, 0.3 stars; 95% CI, −0.02 to 0.7 stars). Hispanic enrollees had a 0.6-star lower simulated rating (95% CI, 0.2-1.0 stars) in 4.5- to 5-star contracts and no statistical difference in 2- to 2.5-star contracts (difference, −0.01 stars; 95% CI, −0.5 to 0.4 stars).”

The study authors pointed to several factors that might explain these disparities, “including access to care, plan cultural competence, access to high-quality or racially concordant health care professionals, and other facets of structural racism.”

As for what can be done to address the issue, Damberg and Elliott proposed a four-step approach:

• Measure performance accurately to reduce provider incentives to avoid disadvantaged patients.
• Make disparities visible through public reporting of stratified performance.
• Specifically incentivize providers and health plans to improve care for disadvantaged patients.
• Modify performance-based payment systems to avoid redistributing resources away from providers who care for disadvantaged patients.

Study limitations included an inability to calculate ratings using the exact methods CMS employs due to restrictions in available data; not all MA contracts were included in the final analysis; the sample sizes for some comparisons may be small; Black and Hispanic enrollees had lower response rates to the CAHPS and HOS than White enrollees; and, while the study authors intentionally combined Hispanic ethnicity and race into one variable to align with CMS methodology, “these identities are multidimensional, and this approach may not have captured the experience of all beneficiaries,” Meyers and colleagues wrote.

1. Medicare Advantage (MA) star ratings are not representative of quality of care for enrollees from racial/ethnic minorities and those with low socioeconomic status (SES).

2. MA contracts with higher star ratings had larger racial/ethnic disparities than did those with lower star ratings, and the contracts with lower concentrations of individuals of low SES and Black or Hispanic individuals had larger disparities and worse quality for these individuals.

John McKenna, Associate Editor, BreakingMED™

Cat ID: 463

Topic ID: 88,463,282,464,494,728,791,509,556,730,192,255,463,60,925