How and why Medicare Advantage plans are rated

Podcast transcript

INTRO
?Welcome to Docs in a Pod, presented by WellMed. Over the next half-hour, Docs in a Pod will educate you about the health and wellness of adults everywhere. Co-hosts, Dr. Tamika Perry, and award winning veteran broadcaster Ron Aaron will share information to improve your health and wellbeing. And now here are Ron Aaron and Dr. Tamika Perry.

RON AARON
Well, thanks everybody for joining us today on Docs in a Pod. Delighted to have you with us. The award winning docs in a pod comes to you every week as we take a look at a variety of Medicare and related issues as they affect seniors and others. We also are available on the radio in Texas and in Florida and a number of different markets. Our podcast is available wherever you listen to your podcasts. We're delighted to have our co-host Dr. Tamika Perry with us. Tamika is a doctor of osteopathy, has a master’s in public health, serves as an associate medical director at WellMed, and she's at the Redbird Clinic up by Dallas. She earned her undergraduate degree from Prairie View A&M University then went on to graduate from Philadelphia College of Osteopathic Medicine, where she was a National Health Service Corps scholar. Next, she completed her family medicine residency at Methodist Charlton Medical Center, where she served as chief resident. Tamika is board certified by the American Osteopathic Board of Family Physicians. She went on to earn a master's in public health with an emphasis on health management and policy at the University of North Texas Health Science Center. And there's more. Dr. Perry is a diplomat of the American Board of Obesity Medicine. When she's not carrying all that baggage around, she and her daughter love to travel. Hey, Tamika, it's great to have you with us again.

DR. TAMIKA PERRY
I do like your job. First of all, Ron, I think you made some of that up. That just sounds like a lot, but I appreciate it. Secondly, yes, I was in Thailand recently, which was really awesome, except for I got a little ill on the way home, but the countryside was beautiful.

RON AARON
What brought you to Thailand?

DR. TAMIKA PERRY
I'd never been there before so it was just one of the places I've never been and that's where I went.

RON AARON
Now on your list of hitting all the continents, have you made it yet to Antarctica?

DR. TAMIKA PERRY
No, I haven't made it to Antarctica. I think for my 50th birthday, and I know what you're thinking, Ron, how could you be close to your 50th because you look 17. Thank you, Ron. I appreciate that. For my 50th in three years, I want to possibly go to Chile and then take either a boat or plane to Antarctica and at least take a selfie in Antarctic so my iPhone knows I was there.

RON AARON
That's pretty cool.

DR. TAMIKA PERRY
Yeah.

RON AARON
Does that then complete your visit to all of the continents?

DR. TAMIKA PERRY
No, I still have Australia left. Antarctica and Australia are my two. I was planning on going to Australia and then this wonderful thing called the COVID pandemic happened and that that kind of thwarted that trip in particular.

RON AARON
Isn't an easy hop to Antarctica from Australia?

DR. TAMIKA PERRY
Not quite, Ron. You weren't that much of a geography major, right?

RON AARON
I thought they were like next door.

DR. TAMIKA PERRY
Not quite. I think I'm going to do those in two separate trips.

RON AARON
I love it. Now we're going to take up a topic today with our special guest, Yvette Richardson, looking at the Medicare STARS program. Let me introduce Yvette, who we're delighted to have with us. Yvette is a nurse practitioner in family medicine. She believes care should be a collaboration between patient and provider. She ensures patients understand and agree to treatment before moving forward with a care plan. Yvette is on a rotating cycle, filling in for nurse practitioners and other providers at a number of WellMed clinics. We're so pleased to have her with us. She earned a Master of Science in Nursing from Capella University. Earned her Graduate Certificate in Family Nurse Partitioning from the University of Texas Arlington and is certified by the American Academy of Nurse Practitioners. When she isn't seeing patients, Yvette loves to work in the yard, cook, sew, and spend time with her two cute little grandkids. Yvette, thanks for being with us on Docs in a Pod.

YVETTE RICHARDSON, NP
Thank you so much, Ron. Thank you, Dr. Perry. I appreciate you having me on.

RON AARON
Now, before we get into the Medicare STARS program, we always like to find out what attracted you to becoming a nurse practitioner.

YVETTE RICHARDSON, NP
I tried to think about that, Ron, and I didn't have a reference point family that was in the medical field. I think my practical side just decided that the medical field would be a great fit. I love to care for people. I started my nursing career and was licensed as an LVN in 1993 and have been in RN and my education has just continued and I love everything that I've done in nursing. It's definitely my heart. I am a nurse at heart, and I love what I do.

RON AARON
For a lot of folks who are listening who may have kids or grandkids starting as a licensed visiting nurse, an LVN, that was a great entry point for you.

YVETTE RICHARDSON, NP
It really was. It opened my eyes to everything medical because as I said, I had no reference point, didn't have a chronic illness or parents that had chronic illnesses. So, it wasn't something that I was around growing up at all. But, I needed to find a way to support my family and contribute in a positive manner and I chose the medical field. I am so blessed that I did.

RON AARON
There's no looking back, you would do it again?

YVETTE RICHARDSON, NP
Absolutely. Without a doubt.

RON AARON
We have you talking about the Medicare STARS program, and I fall into that category. I'm not knowing a lot about it. What is it? Why should people care?

YVETTE RICHARDSON, NP
The Medicare STARS program is really an initiative program that was set in place back in the early 2000s by Medicare. As we all know, Medicare is federally funded, comes from our payroll taxes, premiums, all that sort of thing. It’s health insurance for people that are 65 years or older, or some younger people that have certain disabilities. Medicare has multiple parts, and we may have heard them speak about part A, which is hospital insurance. Part B is, is the medical part of the insurance, you know, your doctor's visits and that sort of thing. And then there's part C, that's the Medicare Advantage plan and that's kind of what we're going to talk about. Part D is drug programs. But with Medicare Advantage CMS, which is Center for Medicare and Medicaid Services, they decided that they were going to score these plans. Give the score to the plan to give the public an idea about how each of these plans perform. Because, as you know, it's hard to be an enrollee and just pick a plan off the top of your head. You don't know what to pick. I wouldn't know what to pick.

RON AARON
Hold that thought. I'll come right back to you, but I want to let folks who may have just joined us know you're listening to the award winning Docs in a Pod. I'm Ron Aaron, along with our co-host, Dr. Tamika Perry. Docs in a Pod is available on the radio in a number of Texas and Florida cities. Also available 24/7 on podcast. Wherever you listen to your podcast, you will find Docs in a pod. Can't sleep in the middle of the night? Tune in to Dr. Tamika Perry and Ron Aaron and not saying we'll put you to sleep, but we certainly will entertain you. We're talking today with Yvette Richardson, a nurse practitioner, and we're talking about the Medicare STARS program, which ranks, rates and scores Medicare Advantage programs, I gather, all over the country. If you're picking Medicare program when you turn 65 or you become disabled and you qualify for Medicare, it can help you make that decision. Is that right, Yvette?

YVETTE RICHARDSON, NP
That is absolutely correct. All of this information is available on the cms.gov website and what they do is they've taken about 545 plans across the nation, and they score these plans. The scores are made up of different components that are important for the care and the quality of the health plan. As you know, there are guidelines for getting tests done. There are guidelines for managing chronic conditions and all these kinds of things. How does a consumer pick a plan? Well, they could go to this cms.gov website and they could review things like the five categories that the star scores used. Staying healthy. Managing chronic conditions. The member experience with the health plan. How are member complaints handled? Are there complaints? Then, what about the customer service of that particular health plan? The score is given anywhere from one star to five stars. Five stars is an exceptional plan and there are really very few plans that are five-star. That really does give the consumer the ability to make a good choice for themselves.

RON AARON
Dr. Perry, I'm sure as a provider occasionally you think about, how are my patients going to rank me?

DR. TAMIKA PERRY
Right. A big portion of that, what Yvette mentioned was customer service and the perception of the care that the individual is receiving. It's a big portion of the star, 40 percent or more. You wouldn't go to a restaurant if you got bad service. You wouldn't go to a store if you got bad service. You shouldn't join a plan that you if you have bad service. So, you want to be treated in an equitable, equal, fair manner. You want your questions to be answered when you go to the doctor and that is part of the star rating. Also, as part of the star rating, Yvette mentioned something very important, staying healthy. How well do the clinicians of that plan suggest things like mammograms, colonoscopies to keep us healthy. Managing chronic conditions. What are the, what's the average A1C of that particular plan? How well are they managing cholesterol with certain medications of the plan? The higher the star rating, it implies not only do the recipients of that plan, like the providers, but they're also receiving quality care. So, it's like a combination of the two. When my mom was searching for a plan, I was like, mom, you will go no less than 4.5.

YVETTE RICHARDSON, NP
That's exactly right.

RON AARON
As you said, Yvette, it's easily found on the CMS.gov website. Take apart the kinds of questions that go into each of those five categories of ranking. Let's talk first about customer service. I'm assuming they're asking real live patients a bunch of questions.

YVETTE RICHARDSON, NP
Yes, sir. They sure are. They're doing surveys. They're usually conducted over the telephone, and they start at a particular time of year, and they go for three months or six months for whatever they do. But they ask questions of the of the patients. Like how do you get your questions answered? Are your test results shared with you in a timely manner? Is it easy to get care when you need to get care? Do you get an appointment easily?

RON AARON
Hang on for just a second. We're going to come right back to both you and Dr. Perry. Dr. Perry, I know you want to jump in on this because if you can encourage patients to give you that five rating, life becomes very, very good. You're listening to the award winning Docs in a Pod. I'm Ron Aaron, along with our co-host, Dr. Tamika Perry. We're having a great conversation with nurse practitioner, Yvette Richardson. The Medicare STARS program may not be something you've thought about before, but it is a great guide for you to find a health plan that's right for you. It also gives you a little leverage over that provider. If you don't like what's going on, you can make a difference in their life. You're listening to Docs in a Pod.

AD
Turning 65? It's time for an important choice, deciding what Medicare coverage is best for you. WellMed can help. When you become a WellMed patient, you can connect our primary care with a Medicare Advantage plan. WellMed doctors and care teams spend quality time with you, listening and learning about your health.
WellMed and a Medicare Advantage plan could be right for you. Choose WellMed. Learn more at 866-433-5048. That's 866-433-5048.

RON AARON
We are so pleased you're with us today on the award winning Docs in a Pod. I'm Ron Aaron, along with our co-host, Dr. Tamika Perry, and we're talking with nurse practitioner Yvette Richardson about something you may never have thought about, but it can certainly help you get even better health care. We're talking about the Medicare STARS program and Yvette, you were talking about the kinds of questions that real life patients get asked by the folks from CMS, which is the governing body of Medicare, share more with us about that.

YVETTE RICHARDSON, NP
Patients have referrals that the provider has given a referral to a specialist. If a decision for the referral is denied or a procedure is denied, then how does that health plan deal with those decisions. Are there appeals? Are the appeals handled in a timely manner? Are they fair? Are communication services available for patients that maybe they closed captioning? Or maybe they need translation services, or those things available. All of that is part of the STAR rating.

DR. TAMIKA PERRY
I think it's important to realize that all Americans at some point throughout our lives, we've worked really hard to contribute to the whole Medicare system. This is your health plan that you work for, so you definitely have a say so in it. So, when they call your house and they want to do these surveys or they put them in the mail, I know it may seem like a pain in the patootie, but definitely do it. Sometimes the provider may not even know things are going on in their office. We want to know these types of things. When you called, were you able to get an appointment with me? Did you wait in the lobby too long? When you came to the office, did I have your labs available for you? Were they mailed to your house? Were they sent through a portal? Do I have other reports from the other clinicians? Did I verbalize, I was going over your labs before I came into the room? So that way you know, I was going over your labs before I came into the room. This is what you deserve. Open communication with the providers of your particular plan.

RON AARON
Yvette and Tamika, often you go to a restaurant and when you're leaving they give you a little card that says, please give us a good rating on Google and Yelp. Do you tell your patients you may get a survey?

YVETTE RICHARDSON, NP
We do. We do communicate that. We let them know that there will be surveys coming out and please give us some honest feedback if there is something when we get the results that we can improve on how, what can we do? What can we do to make your experience better? Because at some point, as Dr. Perry said, we're all going to be recipients of health care, either by Medicare or whatever insurance we're using. But we deserve that, right? We only have in our country, in our bucket of money, we only have an amount of money to spend for health care. Let's use our dollars in the best way we can. So, if we are doing something that's not cost effective, if we're not providing the care that we need, then we are not doing any favors for our own health care. We're not doing any favors. We're increasing the cost, but not increasing the quality. And that's just not acceptable.

RON AARON
So, Yvette. When the surveys come back, some clinics and providers do better than others.

YVETTE RICHARDSON, NP
Absolutely.

RON AARON
Do we know why? What makes the difference?

YVETTE RICHARDSON, NP
Well, there are a lot of things that make a difference. Maybe it's the fact that the call center doesn't route the calls to the right place. Maybe the phones aren't being answered, but when those surveys come back to the health plans, the health plans really review that information and push that information out to the providers so that we can make changes to make the experience better for everyone. So, absolutely.

DR. TAMIKA PERRY
Communication is always the key. It is your provider's job to verbalize what's going on and to make you understand. The thing that I hate the most is to see a patient leave my office with that deer-in-the headlight look like what just happened. No, no, no. It is my job to make you understand what happened. Whether I'm drawing pictures on the paper on the table, which I do often, whether I pull out my phone to say, here's the heart. Here's what happened. I have the labs in front of me. I have the specialist's report in front of me. We're going to go over things. This is your health. This is your right. The wonderful thing about five-star plans is that outside the open enrollment period, you can enroll into those plans. Say you're on a plan and it's just not working out for you. Maybe they're a three-star, 2. 5-star and you're like, I don't get any answers. No one's A1C this year and I'm super diabetic. Who's going to do my mammogram? And you have these questions. This obviously is not a five-star plan and it is July, you can enroll in a five-star plan outside that open enrollment period.

RON AARON
Now there's another area that I know has had a lot of attention and that is, as you mentioned earlier, Yvette, referrals to specialists. They also are ranked. The question is, when a provider makes a referral to a specialist, do you take into account where they're ranked? And do you let that patient know I’m sending you to a number-two-ranked specialist or I got a number five here?

DR. TAMIKA PERRY
I do. I take two things into account. Their tier rating, and then also anecdotally my experience with that provider. I always like to say in my head, would I send myself, my mother, my children to this provider? Cause when every patient is sitting there, I make myself and my colleagues say, how would you want your mother, your father, your grandfather approached? How would you want to take care of them? And that extends to referrals. I'm sure Yvette will agree. So, I take this very seriously. I'm a Tier 1 provider, I want to send you to another Tier 1 provider. This is what Tier 1 means. Tier 1 means that they provide evidence-based, cost effective medicine. Not a lot of wasteful spending. What we do when they do implement a plan on you, it is evidence-based medicine. Not just we're throwing a dart in the dark. This is evidence-based medicine. So, if I'm an a-plus provider, I want to send you to another a-plus provider.

YVETTE RICHARDSON, NP
Right. Not always does the patient have that same idea and it is up to us, as Dr. Perry says, it is up to us to let the patient know that this is why I want to send you here. I have had better outcomes, better communication, whatever that may be. It's up to me as the provider to educate my patients on what is good care. What constitutes that a-plus provider, that tier one provider. It's really up to the PCP's office most times to really look at that referral process and let the patient know what's going to go on. If they agree with that plan of care, then move forward with it.

RON AARON
One of the things I'm hearing here, Yvette and Tamika, is that these ratings are not subjective. It's not, oh, I didn't feel right with that person. You're actually looking for evidence-based information on who's providing the quality of care that patients should expect.

YVETTE RICHARDSON, NP
That’s correct.

DR. TAMIKA PERRY
That's absolutely correct. Yvette and I, within our employer, we are ranked in a manner that mirrors what Medicare does to rank the plan. They look at, say, Tamika, how well are you treating your diabetics? What's your diabetic score? What's your average A1C for the patients that you see? How many of your patients have gotten a mammogram? How many have gotten a colonoscopy? They look at these things. They look at, what do your patients say about you, Tamika and Yvette?

YVETTE RICHARDSON, NP
They do. They absolutely do. Doing these screenings can seem like another one? But you know, these are things that we do to keep our patients healthy. We want to keep our patients healthy. We don't want to treat colon cancer, but we can. If we catch it early, we can treat it and it's necessary. We hope not to have to treat it when it's stage four when it's such a burden on this patient. We'd like to catch things early, treat them and then move on with the rest of their lives.

RON AARON
It's interesting. Patients in a way have a lot of control over how their PCP, primary care physician, is rated. If I say, I'm not going to get a colonoscopy, you are dinging your PCP, right? Because they get ranked based on how compliant their patients are.

DR. TAMIKA PERRY
You are, most certainly. It is your body. It is your right. It's also your PCP's job to emphasize the importance of the screening test. My job and Yvette’s job is disseminate information. We're disseminating useful, meaningful information to your health to allow you and I to make a shared decision on what's best for you.

YVETTE RICHARDSON, NP
Exactly.

RON AARON
Now, let's say you've got a new PCP, you've been assigned to and you go in and you meet for the first time. Should you say to that doctor, I'm new to you, where do you rank in this star-ranking young lady?

DR. TAMIKA PERRY
That is appropriate. That information is actually public knowledge. So, yes, it is appropriate. You can very much so ask someone that. Very much so.

YVETTE RICHARDSON, NP
Yep, definitely.

RON AARON
Should you?

DR. TAMIKA PERRY
Yes. If you get with your broker and you're picking a plan, I would do like I told my mother, no less than 4.5. Show me the 4. 5 or greater in my area.

RON AARON
And how did your mother make out?

DR. TAMIKA PERRY
She got a 5-star. She made out well.

RON AARON
From a patient standpoint, will you see a difference in the kind of care you're getting between a 2 and a 3 and a 5?

YVETTE RICHARDSON, NP
Absolutely. Absolutely. If I'm that patient and I'm going to a four and a half to five-star plan, I know that I'm going to get the screenings that are appropriate. I know that I'm going to have good communication with that provider in that clinic, whereas I might not have that with the two-star, and I might not be happy with it and want to switch the next year. So, absolutely. You should see a difference.

RON AARON
I've got to stop you right there. Really appreciate you coming on. Our nurse practitioner, Yvette Richardson, talking about the Medicare STARS program. As always, thank you to Dr. Tamika Perry, our co-host. I'm Ron Aaron. We will talk with you soon on the award winning Docs in a Pod.

OUTRO
Executive producers for Docs in a Pod are Dan Calderon and Lia Medrano. Associate producer is Cherese Pendleton. Thank you for listening to Docs in a Pod presented by WellMed. We welcome your emails with suggestions and comments on this program at radio@wellmed.net Be sure to listen next week to Docs in a Pod presented by WellMed.

DISCLAIMER
This transcript is generated using a podcast editing tool; there may be small differences between this transcript and the recorded audio content.

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