By Carol Gentry
11/01/12 © Health News Florida
Twenty years ago, Humana’s Gold Plus Plan was a mess. Patients went blind and lame, waiting for cataract and knee-joint surgery.
Many doctors who contracted with Humana and tried to help those patients went deeply into debt.
But today, Humana’s Gold Plus HMO is the only statewide Medicare plan to achieve a near-perfect rating in the new 1-to-5-star rating scale, receiving 4 ½ out of 5 stars. No plan in the state got a 5-star rating.
"Humana gets the fact that the future of health care will be driven by being able to demonstrate how well they do what they do — not how much they do," said Jay Wolfson, professor of public health and medicine at University of South Florida. "It shows they're serious about being a real lead player."
How serious? Humana spokesman Mitch Lubitz said that last year, the company paid more than $34 million to nearly 900 primary care physician practices in the state that participated in the Humana Provider Quality Rewards Program.
Gold Plus, which is available in the state's large metro areas, jumped a whole point from last year. That one-point gain means big money in two ways: quality bonuses from the Centers for Medicare and Medicaid Services and a marketing tool to attract new members.
Humana Gold Plus is already Florida's largest Medicare Advantage program, with 260,000 members, and if seniors pay attention to the star ratings, it will grow still larger.
Changing pay in Medicare Advantage
As a way to curtail spending and encourage better quality of care, the Patient Protection and Affordable Care Act ("ObamaCare") proposed trimming Medicare Advantage plan payments but offering plans most of the money back if they achieved average or above-average star ratings.
After 2014, the bonuses will be available only to the best plans, the ones with 4- and 5-star scores. Those plans that achieve 5 stars get to enroll new members all year long, not just during open enrollment.
This week, CMS used the star-rating system to ratchet up pressure on plans that have consistently rated below average -- under 3 stars. This week, the agency began sending out letters to beneficiaries enrolled in such plans, encouraging them to switch during the current open enrollment period, as Health News Florida reported this week.
The star-rating system reflects data measurement of:
--clinical quality, effectiveness, and outcomes -- whether patients get the right things at the right time and whether they get better.
-- member satisfaction, drawn from surveys and complaint records.
--administrative performance, such as how quickly the plan answers calls, pays claims and resolves disputes.
The tools used to come up with the ratings are ones that health plans already use, including HEDIS (for Health Effectiveness Data and Information Set). HEDIS includes 76 specifically-defined measures.
The 'Star Czar'
When Humana-Florida decided to try for the highest rating, it reorganized so that all departments were mindful of quality measurements. And since it wasn't enough to do the right things if no one knew about it, the company provided doctors an incentive to keep accurate records.
"In order to document all this, it takes time, and time is money," said Dr. Scott Latimer, Humana's Central Florida market president for senior products. "(The incentive program) was one way to get the attention of physicians, through rewards for improved performance."
Humana-Florida also appointed a "Star Czar," registered nurse Mercedes Hernandez in the Miramar office, to organize the effort and keep everyone's feet to the fire.
Even members took part, whether they knew it or not. The company offered modest gifts, such as blankets or flashlights, if they showed up for their visits, took the prescribed medicines, and otherwise complied with medical advice.
Health-industry experts' reaction to the news of Humana's Florida score was, generally, "You're kidding," as Mark Cherry wrote at HealthLeaders-InterStudy, which tracks the managed-care market. " We’re just not accustomed to seeing big, for-profit insurers get high marks in the new ratings system."
He said insurers are spending more on patient care to improve their ratings in part because of the Affordable Care Act's requirement that they either spend at least 80 percent of the premium on patients' health care or pay part of it back. This is sometimes called the "medical-loss ratio" in the industry.
Cherry explained how the math works: By bringing its score up from 3.5 stars last year to 4.5 stars for Gold Plus, Humana receives more money per HMO patient each month, with the amount varying by county. In Miami-Dade, Cherry wrote, with the nation's highest payments from Medicare, Humana stands to gain nearly $20 a month per HMO member, or a total of $8.7 million next year for just that one county.
Humana's 4.5 star-rated Gold Plus HMO is available in South Florida, Tampa Bay, Northeast Florida, the Orlando-Daytona Beach area, Pensacola, the North Suncoast, and Manatee and Charlotte counties.
Humana does not offer that plan on the Treasure Coast, in North Central Florida (Ocala, Gainesville, Tallahassee) in Southwest Florida (Fort Myers-Naples), parts of the Panhandle (Panama City, Destin) or Polk County.
In the non-Gold Plus counties, Humana offers alternative plans: Humana Choice, Gold Choice and Reader's Digest Healthy Living. such as Gold Choice. They were rated at 3.5 stars.
Humana spokesman Lubitz explained that the company offers its Gold Plus HMO only in counties where the company has a sufficient network of doctors and hospitals and a significant pool of Medicare beneficiaries.
'Seen the writing on the wall'
Doctors who recall the days when Humana first took over Gold Plus say they're glad to hear how much it has changed. They include Dr. Julio Pagan, who as a St. Petersburg internist in 1991 was forced into Gold Plus when the doctor he worked for signed a risk contract.
In an Oct. 23, 1991 St. Petersburg Times article, Pagan spoke of new patients who were virtually blind because their previous Gold Plus doctor had rationed cataract surgeries to one patient per month. He said Humana would not allow him to refer schizophrenic and suicidal patients to psychiatrists or authorize elective hip replacements.
Pagan said at the time, Humana "turns you into a meanie when it comes to dishing out money."
Now chief information officer for Parrish Medical Center in Titusville, Pagan said he's glad to hear the news about Humana Gold Plus.
"They've seen the writing on the wall," he said.
--Health News Florida, journalism for a healthy state, is a service of WUSF Public Media. Question? Comment? Contact Editor Carol Gentry at 813-974-8629 (desk) or 727-410-3266 (cell) or by e-mail at Carol.Gentry@HealthNewsFlorida.org.