By Linking Payment to Performance, Medicare Advantage’s Five-Star Program is Driving Better Health Across Our Health Care System

As all of us at Humana work to enhance the ways we can help our members improve their health, we take many approaches to this. One aspect of Medicare Advantage that doesn’t get the credit it deserves is the five-star rating program – and how it not only helps people choose their coverage, but also helps drive better health outcomes.

The development of the Star rating program more than a decade ago by the Centers for Medicare and Medicaid Services (CMS) encourages companies like Humana to constantly strive to improve members’ health and experience. That’s because unlike traditional Medicare, Medicare Advantage plans are measured by CMS on a set of core activities, like ensuring members get key preventive screenings, that help drive better health outcomes.

Here’s an example:

In 2018, Humana member Leon K. opened his mail and found a colorectal cancer screening test kit proactively sent to him by our company.

When Leon’s test came back, it showed that he had blood in his stool – an indicator of colon cancer. That test encouraged Leon to make an appointment with his doctor and get a colonoscopy – even though it was five years before his next scheduled test.

The colonoscopy confirmed he had colon cancer.

Thankfully, since his cancer was caught early, Leon had surgery to remove the cancerous area and avoided other costly and invasive treatments, such as chemotherapy or radiation therapy that cause considerable side effects.

Today, Leon remains in remission.  

“I don’t know whose idea it was to send that kit, but that kit caught what I had in time,” Leon said. “You guys saved my life!”

Leon is not alone. Our focus on proactive, preventive care can be lifesaving and life-changing for our members. This approach is also core to the broader Medicare Advantage public-private partnership that creates incentives for companies like Humana to improve people’s health by linking our payment to our performance. This means that when we do a better job improving a member’s health, we receive higher payments, creating an environment that spurs innovation and new quality improvement initiatives.

This makes the Star rating system one of the few transparent measurements in our health care system. Not only does the Star rating program provide valuable information to consumers by rating Medicare Advantage plans on a scale of one to five stars, it also drives competition between plans and has led to improvements in quality of services, increased offerings, lower costs, and overall better health care.

It’s not unlike other rating tools used by consumers — from movie ratings on Rotten Tomatoes to restaurants on Yelp and household appliances on Amazon. In the same way that ratings can help people avoid bad purchases and find the right products, they can also help people navigate a complicated health care system, where much more than a good movie or meal is on the line. Rather, it’s your health, and whether a health plan can help you manage it seamlessly and effectively while keeping your costs down. 

And, the Star rating program is more than a comparison tool to help Medicare beneficiaries select their plan. By linking our payment to activities that drive better health outcomes, it aligns incentives for plans, encouraging us to innovate and deliver proactive, preventive care that identifies and helps treat chronic conditions and diseases at early stages, which can lower costs and improve outcomes.

Studies show that the Star rating program is working. Since the creation of the program, plans have improved on various quality measures, including health outcomes, preventive screenings, and patient experience. These measures range from controlling blood sugar if you are diabetic to ensuring patients get regular preventive screenings, schedule appointments quickly and access the right prescription medication. And patients are acting accordingly — selecting higher quality plans and switching from lower to higher quality plans.

Today, 92 percent of our Medicare Advantage members are enrolled in plans that have a four-star or above rating, outpacing the industry average and helping us deliver better health outcomes and lower costs for thousands of our members.

One of the major ways we do this is by finding innovative ways to encourage our members like Leon to get preventive screenings, which can help them improve their health and avoid disease progression and avert preventable adverse health outcomes.

Take diabetes and colorectal cancer as an example. By 2030, it’s estimated that more than 55 million Americans will have diabetes. When not managed well, diabetes can have a dramatic effect on health, quality of life, and cost of care. For a Medicare beneficiary, low severity diabetes costs about $600 a month, whereas high severity costs upwards of $4,500 a month. Similarly, while survival rates for colorectal cancer have increased since the 1980s, it is still a leading cause of death for many Americans. Catching colorectal cancer early is critical to effective treatment.

That’s why we meet members where they are – at home. We proactively mail easy-to-use colorectal cancer screening and diabetes testing health kits to qualifying members’ homes to identify cases of colon cancer earlier – when they are more successfully treated – or to assess a patient's diabetes management to tailor therapy and reduce complications of the disease. We also hold health fairs in communities across the country where we provide those same health test kits, perform mammograms, and offer diabetes-related eye exams and bone density tests, as well as deliver educational materials to help prevent chronic conditions from occurring or getting worse.

To be sure that screenings are effective, we make sure that the member’s test results get to their care providers and, if the results are unfavorable, that an appointment with their doctor has been scheduled. If we don’t see an appointment after an abnormal test result, we follow up with the member and his or her provider to help ensure no one falls through the cracks. 

This outreach makes a difference. After Reba C. – another Humana member who received an abnormal colorectal test result – hadn’t followed up with her doctor for a colonoscopy, a nurse from the Humana Stars Outreach Team reached out to Reba and encouraged her to get it checked out. Our nurse answered Reba’s questions and talked her through colon cancer survival rates when it’s found and treated early. After our call, Reba got the treatment she needed.

As a result of this outreach, nearly 93,000 Humana members who should have taken a colorectal cancer screening but didn’t do so in 2017 received one in 2018 – resulting in more than 650 colon cancer diagnoses. Similarly, more than 28,000 members who should have taken a mammogram in 2017 received this test in 2018, resulting in nearly 700 breast cancer diagnoses. And more than 11,000 members with diabetes received a kidney screening in 2018, resulting in more than 1,100 diagnoses of kidney disease.

Stories like Leon’s and Reba’s show the very personal effects that are possible when innovation is applied to a large population. We understand the responsibility that has been entrusted with us by participating in the Medicare Advantage program. We are committed to proactively serving our members by finding new and better ways to foster preventive care and achieving better health. The Stars program is a critical tool in helping us achieve that goal.