Risk Adjusting Medicare Advantage Star Ratings for Socioeconomic Status

Margaret E. O’Kane, MHA, President, National Committee for Quality Assurance

The National Committee for Quality Assurance (NCQA) strongly disputes the suggestion that Medicare should adjust Medicare Advantage (MA) star ratings measures for socioeconomic status (SES).1

It is true that plans with large low-SES patient enrollment perform worse on some measures—on average. However, this association does not prove causation. Some plans with large low-SES populations (more than 75% dually eligible) perform well above average on key Healthcare Effectiveness Data and Information Set measures. These include breast and colon cancer screening, treatment of high blood pressure and rheumatoid arthritis, diabetic blood sugar control, and osteoporosis testing.2 The Figure shows the array of breast cancer screening measure scores among plans by the percentage of dually eligible enrollees in each plan. Some plans with more than 75% dual enrollment nonetheless are above the 80th percentile on their performance. These plans perform well because they understand they can do so, regardless of patient income, by delivering person-centered care.3,4

More importantly, adjusting quality scores for SES merely masks disparities in care without doing anything to address disparities. This unfairly locks in lower expectations for the populations that are most in need of better quality.

There are much better ways to address disparities that do not mask very real differences in quality. First, Medicare should adjust base payments to MA plans for enrollee SES—and has done so since 2017—which gives plans with low-SES enrollees the resources to meet these patients’ greater needs.5 Adjusting base payments, rather than quality measures and the bonuses based on them, does not mask disparities or falsely dismiss them as something that plans cannot address. Second, NCQA is stratifying results by SES for measures with persistent SES-related disparities. Stratification highlights where plans need to focus to reduce and ultimately eliminate disparities.6 Third, sharing best practices of plans and providers who achieve good outcomes in lower-SES populations also helps address disparities.
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