Debbie Zimmerman, MD, is the corporate chief medical officer at Essence Healthcare, a top-rated Medicare Advantage plan serving 63,000 members across eight states.
St. Louis-based Essence is owned and operated by Lumeris, a value-based managed care platform that partners with health systems.
As the senior care industry faces falling average star ratings and mounting quality measurement challenges, Dr. Zimmerman sat down with Becker's to discuss how Essence's HMO plan has consistently received a 5-star rating from CMS.
Question: Only 57 Medicare Advantage contracts received five-star ratings this year, which is down from 74 in 2022. What exactly is the secret that most plans are missing?
Dr. Debbie Zimmerman: It all comes down to four categories: our clinical model, company culture, provider partnerships, and data and technology.
1. Clinical model: The Lumeris model is what you actually need to drive quality outcomes and value-based care. We try as hard as possible to be data driven, and so we do a lot of work around the difference between a high-performing group and a high-opportunity group — then we identify their drivers.
We also work with all of our groups around physician leadership and mentoring, making sure that within a group and within our organization, we're decreasing the variation. Even in a high performing group, there is always an opportunity to improve through the right information, the right incentives and the right governance. We believe the key to value-based care is the delivery of accountable primary care, and many of the quality measures are about the care delivery system. All of our provider organizations have quality metrics in their contracts. The clinical model drives the programs and incentives we're putting in place and is really the key to our success.
2. Company culture: My department coordinates and facilitates star activities, but the whole company understands star ratings. In our all-company meetings, we talk about star ratings as one of our corporate objectives that everybody is held to, along with continuous improvement. We've been rated five stars for two years, but we're sort of obsessive about where there is more opportunity to improve. I think the nimbleness of our company also helps.
3. Provider partnerships: Essence is built so that every patient has an accountable primary care physician and every one of those PCPs is aggregated into a group where we can. Our five star plan is an HMO, and 100 percent of those PCP groups are in a value-based contract with quality incentives. We give the physicians the data to manage it, and then the health plan invests to try and help them improve their metrics. We strive for that model among all of our products to the extent we can do it.
4. Data and technology: We've got a star modeler and we try as much as possible to duplicate the methodology from CMS. We also have a performance platform, LumerisRealize, where we can go in and see how every group is doing at any time down to the subgroup and down to the provider. Our physician leaders can see all of that on their physician dashboards, and then they can act on it.
The other platform, LumerisEngage, is all about coordination. It can basically automate outreach to consumers in collaboration with our providers, and then we supplement with a lot of centralized activities. It automates communication with members, it can interface with EMRs and push clinical insights into the workflow, and the provider can give us information back.
Q: Do you think it's more difficult for large payers to improve their star ratings?
DZ: Star ratings are always evolving, so I think we are potentially able to remain more nimble, and we're more of a collaborative payer with our providers and consumers. Many of the big payers would not be described as collaborative with providers. Plus we're MA-only, and they have big commercial books to prioritize.
Q: Essence expanded to five more states this year — how do you maintain quality while scaling in new environments and to new populations?
DZ: As you move to value-based care, you've got to have a significant volume of patients or revenue in value-based care, otherwise you're not going to change your behavior. The reality is you have to change the way you practice if you're going to actually get the outcomes. When we're new in the market, we want physician mindshare. The most significant thing around mindshare is that we're in those markets with our enablement business already, so we're working with them on all their other value-based contracts. Then Essence comes in with another value-based contract and you've got the same workflow, incentives, and platform.
Q: CMS is proposing a new health equity index for 2027 star ratings. What are your thoughts on that and how should payers stay on top of what is a constantly evolving rating system?
DZ: You have to stay on top of star ratings — be able to adjust your contracts, your data and analytics, and your programs. Star ratings are really hard and you have to run faster to stay the same.
With the health equity proposal, I think we're comfortable with it. There's some details we may not know around the methodology but we think it's fair. Between our compliance team and our clinical analytics team, we've really looked to understand the impact of the proposal and how we want to provide feedback to CMS.
We have a fair amount of robust analytics around social determinants and demographic variables, so we've already identified where there are opportunities around health equity. We are at full risk for a population, so reducing health inequities makes perfect business sense.