Patrice King Brown: Whether you’re new to Medicare, exploring your options, or just want to keep up with the latest in Medicare news, we’ve got you covered.
Stacy Smith: No fluff, no jargon. Just real conversations to help you navigate Medicare with confidence. I’m Stacy Smith.
Patrice King Brown: And I’m Patrice King Brown. Welcome to “Medicare for the Record,” brought to you by UPMC for Life.
Hello and welcome to another edition of “Medicare for the Record,” we're glad that you joined us today. Today we are also joined by Ally Thomas. She's the Associate Vice President of Quality Improvement at UPMC Health Plan, and she's going to explain how the Medicare star ratings system works and how it can be used to help choose a Medicare Advantage plan and why preventive care is important to maintaining health. Ally, welcome. Thanks for joining us. Tell us about yourself.
Ally Thomas: Thank you. Yeah. As you said, I'm the Associate Vice President of Quality Improvement at UPMC Health Plan, and that means that my job is to make sure that our members get the best possible care from their health plans. I work behind the scenes with doctors, nurses, and other care teams to make sure that you get the appointments that you need, that you're getting the services to manage your chronic conditions like diabetes and hypertension, as well as your preventive care, like cancer screenings. So for example, when you are, have a hospital stay, we will have programs so that a nurse follows up with you after you've been in the hospital and make sure you get follow-up appointments that you need.
Stacy Smith: All right, so how does Medicare try to measure the quality of the things you're talking about? And as a consumer, what should we be looking for?
Ally Thomas: So, Medicare rates health plans on a five-star rating system, so you can get anywhere from one to five stars. One means poor quality improvement, five means excellent quality that a health plan has. And so that's determined based on about 40 different measures. So there's a lot of things that CMS looks at in order to determine, is it a great plan that has great quality service for our members? And so that can include things like preventive screening, so are the members getting their cancer screenings, colorectal, breast cancer screening, flu vaccines; as well as are your chronic conditions being managed—diabetes, hypertension, like we just talked about. Whether or not you're able to get the appointments when you need it, that you're able to get the prescription drugs that you need as well as your overall just satisfaction with the plan, so how our customer service is.
Stacy Smith: So Ally, how does Medicare track that?
Ally Thomas: So Medicare gets data from us. We get claims data, we also get survey data—so those surveys all the members take around what their experience is with their doctor and the health plan and their health, CMS uses all of that to then help with determining the quality rating of the program.
Stacy Smith: So the quality rating is the five stars that we're talking about?
Ally Thomas: Yes.
Stacy Smith: All right, great. And so obviously they are important then for us to take a look at.
Ally Thomas: Yeah, they're very important. So it really tells you whether or not you're getting a high-quality plan that provides the care that you need.
Patrice King Brown: So is this information readily available? I mean, basically where do you find that when we're looking? How do I know what the star rating is?
Ally Thomas: Yeah, so when you go, during Annual Enrollment Period when you go to choose your plan, Medicare has available that star rating. So you can compare across all plans what the star rating is in addition to the benefits that they offer.
Patrice King Brown: Does the rating ever change?
Ally Thomas: Every year the rating changes.
Patrice King Brown: Oh…based on whether the company, whether it's successful, still meeting goals, et cetera?
Ally Thomas: So the goals get harder and harder every year. And so every year we're measured on those things like customer satisfaction, and we have to make sure that every year we're making the plan better and better for the members.
Patrice King Brown: So what should consumers consider? Now what if somebody finds a plan that maybe has a lower rating, but the program offers some things that are important to them?
Ally Thomas: So it's really important that you choose a plan that meets your needs. So the star ratings is one of the things that you can look at to help with assessing whether it has what you need, but you want to make sure that your doctors are covered. That's really critical, right? Also that your prescription drugs are affordable. Those are things that you really want to make sure in addition to the star rating that you have. And it's OK to choose a plan that has maybe a slightly less star rating. So maybe, you know, a plan has four and a half stars and another plan has four stars. It's still both good quality plans, but, you know, it's OK to choose the one that's four stars because it covers your doctor or makes sure prescription drugs more affordable. You want to consider both.
Stacy Smith: So Ally, is it difficult to find out whether your particular physician is involved in the plan?
Ally Thomas: No, it's not difficult. You can either call your health plan to find out if your doctor is covered or you can call your doctor's office and ask them.
Stacy Smith: Ally, you indicated that the ratings can change. If I have one particular plan and let's say a three-star and there I see that there's a five-star available to me here, can I make that change sometime during the year?
Ally Thomas: Yes, absolutely. So if there is a five-star plan in your area, you can actually change to that plan throughout the year. You don't have to wait for the Annual Enrollment Period.
Patrice King Brown: Interesting. Yeah, good to know though. That's good information. Do Medicare Advantage plans offer better access to preventive services or wellness programs?
Ally Thomas: Yes. Preventive care is really important to Medicare. So Medicare makes available, at no cost, a lot of preventive services. It's really important that you get your preventive care, like your breast cancer screening or your colorectal cancer screening so that can be detected early, so that you can get the care that you need to really help with better health outcomes. And on top of a lot of that being available at no cost, you can also get rewarded from your plan.
Stacy Smith: How do you mean rewarded?
Ally Thomas: So for example, your plan may offer you $50 for getting your breast cancer screening towards healthy foods.
Patrice King Brown: Just for going?!
Ally Thomas: Yes, just for going.
Patrice King Brown: Something to think about.
Stacy Smith: It is.
Patrice King Brown: And it's important. There's no question about that.
Ally Thomas: It's very important. In addition to cancer screenings, you also want to make sure you get your annual wellness visit. Every year, get your annual wellness visit so that you can make a plan with your doctor around your care to make sure that as you age, you can live well.
Stacy Smith: And what does an annual wellness visit consist of? Is it like a physical examination or just to go in and talk to the doctor? What should it be?
Ally Thomas: All of that. So that's what’s so great about it, right? You get to spend time with your doctor. They do oftentimes things like a physical exam, but you also make a care plan to say, what screenings do you need to get this year? And also, how are you doing with managing your chronic conditions? Is there anything that you should be changing with that? And really just get to talk to your doctor about everything that's going on and how to make that better.
Stacy Smith: So Ally, UPMC has a lot of different kinds of plans on Medicare Advantage. Are each one of them rated separately or are they put in a category and then rated?
Ally Thomas: So it's really important that for every plan that you look at that you're looking at the star rating. It can differ, and so if you're looking at an HMO plan, for example, compared to a PPO plan, you're going to want to compare the benefits, right—the benefits are different that you get for HMO and a PPO plan—and then the star ratings can differ as well. So you definitely want to check that for each of your plans.
Stacy Smith: So Ally, we've had a guest who's told us that a lot of people will take a look at the price point of a particular plan and try to make their decision. You're saying you should also take a look at the star rating. Can you have a good price point and a lower star rating, or is there maybe something you should really take a closer look at that?
Ally Thomas: Yeah, so there's a lot of plan options that are affordable and have great quality and that's what you want to look for. So when you're first looking maybe at the price point to make sure that you can afford the plan, next you can compare the star ratings and maybe you want to choose one that has a little bit of a higher star rating than another so that you make sure that you can get all of the care that you need.
Patrice King Brown: Well, these are all good things to know though, just to be sure what's happening. I don't know that I've ever paid attention to the star rating system, so it's really good to know that that's a tool that is out there and available. Where could we get more information about this?
Ally Thomas: So on Medicare's website, medicare.gov, they do talk more about what the star rating is. You can also go to UPMC for Life's website as well to find more information about our plan and the star ratings.
Patrice King Brown: Ally, thanks so much for sharing your expertise [and] the information today. And we want to thank you for joining us as well for “Medicare for the Record.” Three things for you to take from our conversation today: We want you to know that understanding the star ratings helps you choose wisely. The rating system is based on 40 performance measures, including patient satisfaction, clinical outcomes, and service delivery. And this all helps members compare and select high-performing plans.
Stacy Smith: Of course, higher ratings can mean better quality and performance, and plans with more stars tend to offer better care. They also offer a better customer service and health outcomes. So if a five-star plan is available in your area, you may be able to switch outside of the regular enrollment periods as well.
Patrice King Brown: And preventative services and wellness visits are crucial. Medicare Advantage plans often encourage access to preventive services at no cost to the members—remember that—and annual wellness visits and screenings can help detect health issues early and some plans even reward members for completing them. Once again, thank you for joining us. We hope you'll join us for our next episode of “Medicare for the Record.”
Thanks for tuning in to “Medicare for the Record,” brought to you by UPMC for Life. To learn more about your Medicare options, visit upmchealthplan.com/fortherecord.
This podcast is provided for general informational and educational purposes only. It is not medical care or advice. For questions regarding medical care, please consult with your health care provider. Views and opinions expressed by the participants are solely their own and do not necessarily reflect those of UPMC Health Plan, its subsidiaries, parents, or affiliates.
Every year, Medicare evaluates plans based on a 5-star rating system. UPMC for Life has a contract with Medicare to provide HMO, HMO D-SNP, and PPO plans. The HMO D-SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., UPMC Health Benefits Inc., UPMC for You Inc., and UPMC Health Coverage Inc.
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