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Very poor, very sick elderly do worse in Medicare programs due to circumstances

Study by Medicare-Medicaid insurers say CMS cannot expect same healthcare results as for those from better environments

By Tucker Sutherland, editor

caregiver holding hand of very sick elderly womanApril 1, 2015 – If you are very, very poor and very, very sick – as are most Americans known as “dual eligibles” by the Centers for Medicare & Medicaid Services – you are likely to fair worse than others being treated with the same level of care by Medicare healthcare providers. This is the conclusion from a study funded by a healthcare technology company and the Special Needs Plan (SNP) Alliance, a group of companies that offer Medicare-Medicaid insurance plans.

A news release issued by the technology firm, Inovalon, says this was the largest analysis ever performed on dual eligible quality outcomes. Dual eligibles are people who have been qualified by the CMS as being entitled to services under both Medicare, which is generally for all Americans age 65 and older, and Medicaid, which is for those with very low incomes.


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The study analysis said the dual eligibles “have worse health outcomes that cannot be attributed to a health plan’s quality of service. Moreover, additional factors beyond the high-risk chronic health conditions that members present may contribute to worse health outcomes.”

The study findings also “indicate that Medicare Advantage (MA) plans serving disadvantaged beneficiaries may provide higher-quality care than their ratings reflect under the current Five-Star Rating System Medicare uses to assess the performance of plans. This is the first large-scale, independent study to investigate health outcomes of Medicare beneficiaries enrolled in MA plans at the member-level.”

Christie Teigland, Ph.D., senior director of statistical research at Inovalon and principal investigator of the study, said, “This is an important, ground-breaking analysis of data not previously achievable in the industry.”

“The results show that a higher prevalence in the dual eligible population of high-risk clinical conditions, sociodemographic factors such as living in a high poverty area, and community resource factors such as living in an area with a shortage of primary care physicians, result in worse outcomes given the same access and quality of care.”

“The study provides compelling evidence that quality measures in the Five-Star Rating System do not fully capture the complexity of the circumstances in which Medicare’s dual eligible population lives or the complexities involved in their health care,” said Richard Bringewatt, president and chair, SNP Alliance.

“Performance measures must take this evidence into account for health plans to have an accurate quality rating system. Plans and providers that serve disadvantaged populations, such as MA Special Needs Plans, should also take this evidence into account as it sheds light on a range of sociodemographic factors that, if properly addressed, could help us develop and target more ways to improve health outcomes for our members.”

“We’ve suspected all along that the poorer health outcomes of dual eligible members are not caused by the quality of plans, but are due to other factors,” said Dr. Paige Reichert, medical senior director of quality, Cigna HealthSpring.

“If the disparity of outcomes between dual eligible and non-dual eligible members were due to the quality of care provided by the plan, the results would have been similar between both groups. However, because the study controlled for similar member characteristics, we see that it is sociodemographic factors that are affecting health outcomes. Clearly the issues that are affecting the health outcomes of disadvantaged beneficiaries need to be addressed to eliminate health disparities, and should also be taken into account when measuring the quality of Medicare managed care plans.”

The news release said, “Insights gained from this analysis will empower new advancements in Inovalon’s patient-level and provider-level analyses technologies designed to achieve greater insight into the identification of gaps in care, quality, and financial performance, as well as the intervention platforms needed to resolve such gaps.”

About the Research

Inovalon conducted this research in collaboration with Cigna-HealthSpring, WellCare, Healthfirst, Gateway Health, BCBS Minnesota and Blue Plus, Health Care Service Corporation (HCSC), the Special Needs Plan (SNP) Alliance, and Medicaid Health Plans of America (MHPA), and consulted with multiple other industry partners.

For its research, Inovalon says it used member-level Medicare Advantage data from a number of collaborating health plans and de-identified data extracted from its Medical Outcomes Research for Effectiveness and Economics Registry (MORE2 Registry®), one of the industry’s largest healthcare datasets. These datasets were combined with additional sources, including CMS Monthly Membership Reports, U.S. Census data, and detailed data on sociodemographic and community resource availability. The study evaluated performance on 18 Five-Star quality measures for more than 2.2 million Medicare Advantage members, drawn from 81 separate Medicare Advantage contracts comprising 364 individual health plans.

>> An Investigation of Medicare Advantage Dual Eligible Member-Level Performance on the Centers for Medicare and Medicaid Services (CMS) Five-Star Quality Measures.”

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