Managing Editor's Memo

Medical Directors' Fate Rests in the MA Stars

Frank Diamond

Spoiler alert, but only blue (guarded) because the movie Captain Phillips is based on something that really happened. One of the more affecting scenes comes at the end when a Navy medic examines the hero. The director uses a real medic, and Corpsman Danielle Albert plays herself beautifully.

She examines the traumatized hero while asking questions in a manner that mixes clinical detachment with just the slightest pinch of empathy. She’s doing her job. They told her to treat the scene as a drill and anyone familiar with life on a Navy destroyer knows that drills take up a good part of each day.

You don’t have to be in the Navy to identify with that character. Medical directors keep their cool as well. They are trained to do so in medical school and it carries over when they become businesspeople.

Well, the pressure’s on. Our cover story examines the challenges – and the stakes – presented by the Five Star Quality Rating System for Medicare Advantage Plans. One star can add up to millions of dollars in bonuses. Not only that, but high-achieving plans can enroll beneficiaries all year round.

It all comes down to quality. The Centers for Medicare & Medicaid Services notes, “Outcome and intermediate outcome measures continue to be weighted three times as much as process measures, and patient experience and access measures are weighted 1.5 times as much as process measures.”

Executives in MA plans are scrambling, but medical directors who specialize in quality assurance will be particularly challenged, notes Jaan Sidorov, MD, a member of Managed Care’s Editorial Advisory Board. “It’s hard to overestimate the luster of the money from increased payments and the threat of being put on the MA naughty list, let alone having your competition outpace you.” Good luck.


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