The Ratings Game
Open Minds | By Monica E. Oss
$11.8 billion. That is how much Medicare health plans received in 2024 in bonus payments as a result of Medicare star ratings—a number that has more than tripled since 2015 (see Medicare Advantage Quality Bonus Payments Will Total At Least $11.8 Billion In 2024).
The most recent development is that a federal judge has ordered the Centers for Medicare & Medicaid Services (CMS) to recalculate UnitedHealthcare’s Medicare Advantage (MA) star ratings for 2025. While the judge did not agree with UnitedHealthcare’s assertion that CMS held them to a different standard than other insurers, the court ordered CMS to reduce the weight of call center metrics in calculating star ratings. The recalculated ratings could increase UnitedHealthcare’s MA earnings by $10 million (see CMS Ordered To Recalculate UnitedHealthcare’s 2025 MA Stars).
UnitedHealth Care isn’t the only Medicare Advantage plan that has sued about its ratings (see Seeing The Stars). Elevance Health, Centene, and Humana have also challenged their ratings and bonus payments (see Elevance Health Sues HHS Over Medicare Advantage Star Ratings, Centene Sues HHS Over Medicare Advantage Star Ratings Fall, and Humana Sues US Health Agencies). Elevance claims that federal regulators employed an “arbitrary and capricious” approach to calculating quality scores, resulting in a miscalculation that has cost the company at least $375 million in bonus payments and rebates, Humana has made a similar claim. Meanwhile, Centene is seeking a court order directing the CMS to recalculate its ratings, excluding the impact of a mishandled “secret shopper” call, which it argues could result in a $73 million in revenue.
And just this month, Alignment Healthcare became the latest plan to file suit to improve their ratings (see Alignment Healthcare Sues CMS Over Star Ratings, Disapproves Of Federal Contractor’s Role). Alignment alleges that CMS ratings, which are based on “objectively bad data science,” were calculated incorrectly. Furthermore, the company argues that the CMS claims the appeals process misclassified one of its appeals, causing a two-star reduction—from five stars to three—on one measure. Additionally, Alignment contends that the CMS wrongfully overturned a claim denial.
Health plan executives are focused on CMS Star Ratings and National Committee for Quality Assurance (NCQA) scores because they translate into plan revenue. And for provider organization executives who want ‘preferred’ relationships with those health plans understanding the health plan performance metrics —and being able to demonstrate how they support improving those measures—is critical. For an update on the health plan performance issues and rating systems, check out these resources in the OPEN MINDS Industry Library. |
DEA Proposes Special Registrations for Telehealth Prescribing
TechTarget / By Anuja Vaidya
The DEA is set to publish a proposal for a special registrations framework that would allow certain healthcare practitioners to prescribe controlled substances via telehealth without performing an in-person exam first.
The unpublished proposal made available on the Federal Register details the special registrations framework, which includes three types of registrations:
- A telemedicine prescribing registration would authorize qualified clinician practitioners, including registered physicians and midlevel practitioners, to prescribe Schedule III-V controlled substances via telehealth.
- An advanced telemedicine prescribing registration would allow specialized clinician practitioners, such as psychiatrists and hospice care physicians, to prescribe Schedule II-V controlled substances via telehealth.
- A telemedicine platform registration would authorize covered online telehealth platforms to dispense Schedule II-V controlled substances.
Once registered, clinician practitioners would be considered clinician special registrants, and covered online telehealth platforms would be regarded as platform special registrants.
The proposal also requires the registrants to maintain a state telemedicine registration for every state where a patient is treated. The DEA will issue the state telemedicine registration, which, along with the other registrations, would run on a three-year cycle…
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Health Programs on the GOP Chopping Block
Politico / By Chelsea Cirruzzo
Driving The Day
Many GOP lawmakers want to let ACA health insurance plan subsidies expire, but GOP Sen. Lisa Murkowski feels differently. | Francis Chung/POLITICO
GOP FLOATS HEALTH CARE CUTS — House Republicans are circulating a menu of options amounting to more than $5 trillion in cuts they could use to bankroll President-elect Donald Trump’s top priorities this year.
On the table: changes to Medicare, Medicaid and the Affordable Care Act. The list from the House Budget Committee could be used to finance a party-line reconciliation bill or other spending reduction efforts. The proposed cuts are highly ambitious, but not all are likely to become law, given the narrow margins for Republicans in the House and Senate.
I caught up with POLITICO Congress reporter and former Pulse author Ben Leonard to discuss the state of play.
There would be a few different ways on this “menu” to cut Medicaid. Can you walk us through them?
One big target is per-capita caps, favored by House Energy and Commerce Chair Brett Guthrie (R-Ky.). They’d allocate a set amount of Medicaid funding based on population instead of being an open-ended entitlement. That’s projected to save up to $918 billion.
Another major target is equalizing payments for nondisabled adults with those of traditional Medicaid enrollment — those with disabilities or low-income children, which [Republicans] say would save up to $690 billion.
Adding work requirements in the program is also on the table and is pegged to save $120 billion.
Which ones would get the most opposition from Dems?
They’d pretty much all be nonstarters for Democrats and even some Republicans. Medicaid insures more than 70 million Americans, and any legislation that might reduce coverage in the program would be fiercely opposed by Democrats and could be a tough vote for Republicans in swing districts.
The proposed ACA changes involve enhanced premium tax credits that expire at the end of the year, setting up a major policy battle.
Democrats broadly support extending the enhanced subsidies, which have lowered premium costs for many Americans and led to record ACA marketplace enrollment. Many Republicans support letting them expire, arguing they’re raising health care costs, but moderate Sen. Lisa Murkowski (R-Alaska) recently said she supports extending them. Either way, Republicans will have a difficult choice: spend hundreds of billions to buoy Obamacare enrollment or raise premium costs significantly heading into an election year in 2026.
Are there any proposals that could get bipartisan agreement?
Site-neutral payments are a more bipartisan option under consideration. Limiting eligibility for ACA plans based on citizenship status could receive more bipartisan interest than it might have previously, given Democrats’ pivot on immigration after a tough election cycle. But most of the options are not expected to receive much, if any, Democratic support…
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Flu, RSV, and Norovirus Are in Full Swing, While COVID Looms
Medscape / By Lisa O’Mary
Most US states are reporting high or very high flu-like activity, while COVID-19 rates remain lower than this time last year.
The nation isn’t out of the woods yet, though, in terms of seeing another tripledemic or even quad-demic.
So far this year, the CDC estimates that 5.3 million people nationwide have had the flu, and the virus has hospitalized 63,000 people, as well as contributed to 2700 deaths, including 11 children.
Nearly 19% of influenza tests are positive, as are about 13% of tests for respiratory syncytial virus (RSV) and 7% of COVID tests, according to CDC data.
Those flu and RSV rates are similar to what was seen about this time last year, but COVID is trailing, at about half its seasonal rate. Also, COVID hospitalization rates are less than half of what they were at this time last year.
Based on wastewater surveillance data, which can help predict whether viruses are expanding or receding, RSV and COVID may still be on the upswing. The CDC says COVID wastewater activity detections are “high.” And eight US states recently reported “very high” RSV detections: Connecticut, Georgia, Louisiana, Maryland, Massachusetts, New Mexico, Pennsylvania, and South Carolina. Another 14 states logged “high” RSV wastewater levels, CDC data show.
Flu detections in wastewater monitoring nationwide is currently shown as “moderate” by the CDC, which only tracks influenza A — the type that accounts for most flu cases.
Meanwhile, norovirus rates have hit what is at least a 5-year high, with positive tests topping 22%, according to data through the end of December. Seasonal norovirus high positive test rates are typically 15% or lower.
The CDC is expected to release updated virus data early this week that will give the first look at post-holiday impacts.
SOURCES:
CDC: “National Respiratory and Enteric Virus Surveillance System (NREVSS),” “COVID-NET Weekly Rates of COVID-19 Associated Hospitalizations (Week End Date 1/4/2025),” “Wastewater COVID-19 National and Regional Trends,” “RSV Current Wastewater Viral Activity Levels Map.” |
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