Representatives Blumenauer, Black Send Letter to CMS on Socioeconomic Status and Risk-Adjustment in Medicare Advantage

Washington, D.C. –(ENEWSPF)—November 18, 2014. Reps. Earl Blumenauer (D-OR-03) and Diane Black (R-TN-06) and a bipartisan group of 32 of their House colleagues wrote to the Centers for Medicare and Medicaid Services Administrator, Marilyn Tavenner, asking for appropriate adjustments to the Medicare Advantage risk-adjustment system and the star rating and quality bonus program for Medicare’s most vulnerable population.  The text of their letter is below, or for a digital copy, click here.

The Honorable Marilyn Tavenner
Administrator, Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

Dear Administrator Tavenner:

We write today to urge the Centers for Medicare and Medicaid Services (CMS) to take appropriate measures to ensure Medicare’s most vulnerable populations will continue to have access to the high quality care provided through the Medicare Advantage (MA) program. The MA program plays an important role in helping 16 million beneficiaries access high-quality health care, including delivering coordinated care to dually-eligible beneficiaries and other low-income seniors who often experience higher rates of chronic illness, disability and mental illness.  

It is well established that social determinants of health, including socioeconomic status, are important drivers of health outcomes. Dually-eligible individuals are amongst Medicare and Medicaid’s most vulnerable beneficiaries and those most in need of the additional benefits and services, care management, and coordination across providers that MA offers.  We are, therefore, concerned that the current MA quality and resultant payment system does not capture the social determinants of health that these beneficiaries may face.

We appreciate CMS’s recent interest in the impact of such social determinations, including low-income status on performance ratings, and believe the Request for Information released on September 8, 2014 is an important first step in examining this issue.  The current MA payment system—specifically the risk adjustment payment model and the star ratings and quality bonus program—does not adequately recognize the types of high-cost interventions and care management required to provide high-quality care to the unique and specific needs of dually-eligible beneficiaries.  

Even with additional resources and the best efforts of health care providers, improved health outcomes tend to occur at a slower rate for the most disadvantaged beneficiaries.  This, in turn, leads to lower quality ratings for the plans serving these populations and ultimately, lower funding to these plans. Thus, our current system perpetuates a downward funding and quality spiral for the populations who may need the most help.  

The possibility that a transfer of resources would be made away from the very beneficiaries most in need of such investments is deeply concerning. We want to hold all MA plans to high standards, but we also need to better measure patient outcomes and hold plans accountable for the risks and challenges faced by vulnerable beneficiaries and provide the right resources to help address those risks.  

The MA payment system should recognize the differences necessary to improve health outcomes for all populations, not discourage it.  Any improvement to the risk adjustment model should consider MedPAC’s recommendations to use two years of condition data in the risk adjustment formula, include the number of conditions as an adjustment factor, and include variables for partial and full dual status.   In addition, the star ratings should be adjusted to reflect the challenges plans and providers face in caring for the most vulnerable populations.  

The National Quality Forum (NQF) has recognized the impact that socioeconomic factors have on health outcomes and finalized recommendations to adjust quality measures for such factors on a trial basis.   We applaud NQF for their efforts to address this issue, and we strongly encourage CMS to take these recommendations into account as you consider improvements to the Medicare Advantage program.

We appreciate the recent effort of CMS to consider this important issue, and respectfully request that CMS make the necessary adjustments in the short term to ensure that both the risk-adjustment system and the star rating and quality bonus program accurately reflect the challenges in caring for vulnerable, dually-eligible individuals.  We look forward to further working with CMS to further ensure Medicare’s risk adjustment and quality measurement system is as accurate as possible.