INSTITUTIONAL RACISM & CLASSISM
Association of Medicare Advantage Star Ratings With Racial, Ethnic, and Socioeconomic Disparities in Quality of Care
Question Do Medicare Advantage star ratings, which are generated using data from all enrollees in a plan, reflect the quality experience of racial/ethnic minorities and enrollees with low socioeconomic status (SES)?
Findings This cross-sectional study of 1 578 564 Medicare Advantage enrollees found that simulated star ratings for persons with lower SES and Black and Hispanic enrollees were substantially lower than ratings for those with higher SES and White enrollees in the same contract. There was little correlation between ratings for each group, and higher-performing plans, as measured by the star rating, had larger racial/ethnic and SES disparities in care.
Meaning Medicare Advantage star ratings, which are designed to reflect overall performance in a plan, are only modestly associated with quality for racial/ethnic minorities and enrollees of low SES in the same plan.
Importance Medicare Advantage (MA) plans, which disproportionately enroll racial/ethnic minorities and persons with socioeconomic disadvantage, receive bonus payments on the basis of overall performance on a 5-star rating scale. The association between plans’ overall quality and disparities in quality is not well understood.
Objective To examine the association between MA star ratings and disparities in care for racial/ethnic minorities and enrollees with lower income and educational attainment.
Design, Setting, and Participants This cross-sectional study included 1 578 564 MA enrollees from 454 contracts across the 2015 and 2016 calendar years. Data analyses were conducted between June 2019 and June 2020.
Exposures Self-reported race and ethnicity and low socioeconomic status (SES) (defined by low income or less than a high school education) vs high SES (neither low income nor low educational attainment).
Main Outcomes and Measures Performance on 22 measures of quality and satisfaction determined at the individual enrollee level, aggregated into simulated star ratings (scale, 2-5) stratified by SES and race/ethnicity.
Results A total of 1 578 564 enrollees were included in this analysis (55.8% female; mean [SD] age, 71.4 [11.3] years; 65.8% White; 12.3% Black; 14.6% Hispanic). Enrollees with low SES had simulated stratified star ratings 0.5 stars lower (95% CI, 0.4-0.6 stars) than individuals with high SES in the same contract. Black and Hispanic enrollees had simulated star ratings that were 0.3 stars (95% CI, 0.2-0.4 stars) and 0.1 stars (95% CI, −0.04 to 0.2 stars) lower than White enrollees within the same contracts. Black enrollees had a 0.4-star lower rating (95% CI, 0.1-0.7 stars) in 4.5- to 5-star contracts and a no statistical difference in 2.0- to 2.5-star–rated contracts (difference, 0.3 stars; 95% CI, −0.02 to 0.7 stars). Hispanic enrollees had a 0.6-star lower simulated rating (95% CI, 0.2-1.0 stars) in 4.5- to 5-star contracts and no statistical difference in 2- to 2.5-star contracts (difference, −0.01 stars; 95% CI, −0.5 to 0.4 stars). There was low correlation between simulated ratings for enrollees of low SES and high SES (difference, 0.2 stars; 95% CI, 0.03-0.4 stars) and between simulated ratings for White and Black enrollees (difference, 0.4 stars; 95% CI, 0.3-0.5 stars) and White and Hispanic enrollees (difference, 0.3 stars; 95% CI, 0.2-0.4 stars). As the proportion of Black and Hispanic enrollees increased in a contract, racial/ethnic disparities in ratings decreased.
Conclusions and Relevance In this cross-sectional study, simulated MA star ratings were only weakly correlated with those for enrollees of low SES in the same contract, and contracts with higher star ratings had larger disparities in quality. Measures of equity in MA plans’ quality of care may be needed.
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