CMA Comments re: Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model

September 15, 2015

Submitted electronically

Sheila Hanley
Director, Policy and Programs Group
Center for Medicare & Medicaid Innovation
Centers for Medicare & Medicaid Services
HealthPlanInnovation@cms.hhs.gov

RE: Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model

The Center for Medicare Advocacy, Inc., (Center) appreciates the opportunity to provide comments in response to the recently announced Medicare Advantage (MA) Value Based Insurance Design (VBID) demonstration model.

The Center, founded in 1986, is a national, non-partisan education and advocacy organization that works to ensure fair access to Medicare and to quality healthcare.  We draw upon our direct experience with thousands of individuals and their families to educate policymakers about how their decisions affect the lives of real people.  Additionally, we provide legal representation to ensure that beneficiaries receive the health care benefits to which they are legally entitled, and to the quality health care coverage and services they need.

We believe that VBID—if implemented with appropriate safeguards—can allow CMS to test a model that achieves the triple aim of enhancing beneficiaries’ health care experience, improving population health, and reducing costs for people with Medicare.

We appreciate that the demonstration model reflects CMS’ careful consideration of many important beneficiary protections. We continue to support strong and clear parameters for program design, including: a multi-stakeholder and transparent process for identifying high-value services and developing conditions of participation; permitting only cost-sharing reductions; limiting or prohibiting advertising and other pre-enrollment marketing of cost sharing adjustments; and opt-in beneficiary selection. Many of these elements are reflected in the program announcement.

Our comments identify components of the VBID model that we support and relay suggestions intended to strengthen the model and ensure that the proposed MA VBID demonstration fully meets the needs of Medicare beneficiaries.

General Program Design

We commend CMS for many elements of the proposed VBID demonstration model. In particular, we are pleased to see many essential beneficiary protections reflected in the design, including: an allowance for only lowered cost-sharing and additional benefits for high-value services and care; prohibited marketing of VBID programs; and the retention of anti-discrimination rules. We fully support the conditions of participation for plans – plans under sanction and plans with below-average star rating should not be permitted increased flexibility. We also support the educational requirements and rigorous evaluation, monitoring, and auditing schemes outlined in the announcement.

Utilizing only positive reinforcement in the form of lowered cost-sharing and expanded benefits is an essential component of VBID demonstration models. We strongly commend CMS for allowing only encouragement toward accessing high-value services, rather than discouragement of lower-value services. As this model is tested and as educational activities are implemented and evaluated, we support only these sorts of incentives (in other words, “carrots” v. “sticks”).

Similarly, we do not support waiving existing anti-discrimination rules that prevent MA plans from denying, limiting or conditioning coverage or provision of benefits based on any health status-related factors.[1] Correspondingly, rules should not be changed to allow MA plans to design covered benefits in such a way that is likely to substantially discourage enrollment by certain individuals.  As such, we are glad the model maintains the obligation to provide services that do not target or disincentivize participation or enrollment by health/disability status. We strongly support CMS’ decision not to waive anti-discrimination provisions in this demonstration, coupled with its proposed monitoring of plan design for discriminatory elements, as we remain concerned that too much flexibility risks allowing some MA plans to devise discriminatory plan designs, intentionally or otherwise.   Any flexibility given to MA plans must be subject to transparent, well-developed criteria established by CMS in consultation with other stakeholders, including clinicians, researchers and consumer advocates.

Specific Plan Design

Apply lessons learned and potential successes beyond Medicare Advantage. We are hopeful about the prospects for VBID, and the identification and promotion of high-value services, to improve care and reduce costs for Medicare beneficiaries. While we recognize that CMS’ demonstration model is restricted to MA plans, we note that recent legislative proposals concerning VBID have explicitly sought to prohibit the U.S. Department of Health and Human Services from expanding any VBID demonstration beyond MA to the Traditional Medicare program.[2]

The rewards of intelligently structured insurance, including “encourag[ing] patients to consume high-value clinical services, thereby improving quality and reducing costs” should, to the extent possible, be applicable to all Medicare beneficiaries, regardless of how they choose to access their benefits. Lowering or eliminating cost-sharing in Traditional Medicare, as well as offering some of the other positive incentives outlined in this proposal, could also benefit the majority of beneficiaries who choose to remain in Traditional Medicare.

Should this demonstration result in positive health outcomes for MA enrollees, we hope that CMS will both make lessons learned from this model publically available and, as appropriate, integrate promising practices into the Traditional Medicare program and beyond. Thus, we encourage CMS to evaluate this demonstration program—through design, implementation, and monitoring—in light of how positive results might be expanded beyond the MA program.  

Make the rationale for identifying “high-value” care publicly available. While we appreciate that CMS will be vetting plan criteria for identifying high-value services, we urge CMS to make this rationale publicly available, either as part of the demonstration or along with the evaluation of the demonstration. We appreciate that VBID has the potential to enhance health care transparency—both for cost and quality. As demonstrated by the literature, diminished cost-sharing through VBID also has the potential to improve adherence and health care outcomes, particularly among lower-income, vulnerable populations.[3]

As such, we believe that transparency in the process for identifying high-value services, and particularly high-value providers, is essential. As noted above, this transparency would help facilitate a translation of positive outcomes in the MA arena into actionable steps in Traditional Medicare and other health systems.

Along these same lines, we encourage CMS to limit approval of lower cost-sharing only to instances where there is a well-established evidence-base that illustrates a particular service, prescription medication, or health care provider is in fact “high-value.” We also encourage CMS to develop a standardized list of health care services or prescription drugs that may be subject to altered cost-sharing in consultation with clinicians and other experts.

Carefully vet proposed VBID programs for discriminatory design. As noted above, we strongly support CMS’ decision to retain MA anti-discrimination rules and the agency’s commitment to evaluating proposed VBID programs for potentially discriminatory design. In particular, we have some concerns about the potential for discriminatory impact on dually eligible beneficiaries if a design overly relies on reduced cost-sharing as an incentive for participation. MA enrollees with both Medicare and Medicaid are protected from liability for copayments and deductibles for all Part A and Part B services.[4] 

As such, reducing or eliminating copayments or deductibles provides them with no additional benefit and would not incentivize them to participate. In contrast, we expect that eliminating Part D copayments could be effective since, even at the Low-Income Subsidy (LIS) level, prescription drug copayments can be a heavy burden for dually eligible beneficiaries who need multiple medications. The demonstration could provide valuable data about the validity of that assumption.

Program design can be discriminatory in more subtle ways as well. For example, free gym memberships may be of limited value to some individuals with disabilities that cannot be accommodated in the gym, to those who culturally may be uncomfortable in an environment where men and women are exercising together. VBID benefits need to be sufficiently flexible to accommodate the wide range of needs in the MA population. 

It is also important to note that the principle of non-discrimination is implicated in the selection of high-value providers. If, for example, the offices of a high-value provider are not wheelchair accessible or do not have accessible examining equipment, there is a discriminatory effect on people with disabilities within the targeted population. Similarly, if the high-value providers identified by an MA plan do not have a history of effectively serving limited-English proficient (LEP) individuals, it is unlikely that LEP members will be willing to switch to them.

We ask that CMS take these concerns into consideration when evaluating proposed VBID programs and as the agency monitors the actual implementation of those proposals by participating MA plans.

Rigorously monitor access to high-value health care providers. Another element of this program’s design where we have specific concerns relates to access to high-value providers. We suggest that CMS carefully monitor access and communication regarding the availability of preferred providers. In particular, as contemplated in the 2016 Call Letter relating to MA provider networks generally, we urge CMS to ensure that high-value providers identified by participating MA plans are accepting new patients, so as not to put some MA enrollees eligible for VBID benefits at an automatic disadvantage. In addition, we suspect that communicating to beneficiaries about these tiered networks may be especially challenging. As described below, we encourage careful development and review of all beneficiary communications related to the VBID program, including how to access high-value health care providers.

On this subject, we see potential parallels to preferred pharmacy networks and reduced cost-sharing in the Medicare prescription drug program (Part D) and we request that CMS actively evaluate MA plans for geographic and urban/rural differences in access to high-value providers. As applicable, we encourage CMS to apply lessons learned from recent initiatives, including the agency’s analysis of beneficiary access to preferred cost-sharing pharmacies and modifications to nomenclature on preferred pharmacy arrangements, to the VBID demonstration.[5] Importantly, CMS must ensure that VBID models do not benefit only geographic, economic, or other subsets of MA enrollees.

Evaluation and Monitoring

We strongly support the evaluation processes and related protections outlined in the announcement. The included enrollee protections, like marketing prohibitions, are ineffective and without force unless compliance is monitored and enforced. For this reason, we are pleased that CMS will use “secret shoppers” to help ensure compliance with the model’s marketing protections. We also support the proposed auditing procedures and the customized scripts for 1-800-MEDICARE.

As the program is implemented, we suggest that CMS’ audit results be made public and that diverse stakeholders are engaged and included in the process of developing the 1-800-MEDICARE call scripts. In addition, we appreciate the ongoing monitoring of plan data for coding intensity, enrollee outcomes, enrollee satisfaction, and other factors, and we would recommend that the incoming data, as well as any results or actions that result from the monitoring, be made transparent and publicly available.

Furthermore, while we commend the requirement for a standardized process for receiving and reviewing provider complaints, we recommend that MA VBID program enrollees receive clear communication from CMS on their right to file grievances and appeals and that the model’s data collection include information regarding enrollee grievances and appeals.

Disallowed Marketing to Beneficiaries

We strongly support CMS’ approach to limiting plan marketing as outlined in the program announcement. We applaud the agency for its focus on the potential for enrollee confusion and we appreciate the steps proposed to minimize such confusion. Specifically, we endorse the prohibition on the marketing of any VBID program to beneficiaries not currently enrolled in a participating MA plan.

We believe this prohibition reduces the potential for “cherry picking” of prospective plan enrollees and other potentially discriminatory practices. In addition, this prohibition ensures that individuals attracted to a VBID program who are not ultimately eligible (because they do not have the requisite health condition(s) or do not need certain services associated with the VBID program) do not end up enrolled in an MA plan that otherwise might not be the best choice for them.

We also support permitting participating MA plans to convey information about VBID benefits only after a potential enrollee specifically inquires about them and only after the provision of a CMS-standard written disclaimer concerning the program and potential eligibility. Further, we encourage CMS to require prior review and approval of all written materials, including scripts for oral communication and distribution plans for materials concerning VBID benefits.

We also urge CMS to consider establishing an independent ombudsman program for the purposes of monitoring and assisting beneficiaries in all demonstration programs underway at the Centers for Medicare & Medicaid Innovation (CMMI). Ombudsman programs are being successfully used in the Financial Alignment Initiative for Medicare-Medicaid Enrollees as well as to monitor the Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding program authorized by Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

These independent entities are responsible for monitoring beneficiary access to care, in addition to limiting beneficiary confusion and promoting enhanced understanding. With an increasing number of delivery and payment system models ongoing at CMMI, we believe a dedicated ombudsman is warranted.

Beneficiary and Provider Education and Outreach

Develop uniform beneficiary communications and revisit minimum requirements. We appreciate the minimum requirements for beneficiary communication included in the program design, but we are concerned these requirements fall short of ensuring full understanding among MA enrollees who might access VBID benefits. Like CMS, we do not believe the VBID model will be successful if MA plans adhere only to the minimum requirements outlined by CMS.

To promote beneficiary understanding and choice, we encourage CMS to modify the proposed requirements. First and foremost, we suggest that CMS develop and require the use of standardized templates for use by participating MA plans in the VBID demonstration. At a minimum, CMS should require that all enrollee communications include plain language information about options, rights, and services in the VBID program. These communications should also direct enrollees to 1-800 MEDICARE and State Health Insurance Assistance Programs (SHIPS) that can help enrollees navigate any confusion or problems with access to care.

In addition, we suggest that CMS ensure all enrollee communications are fully accessible to enrollees and their caregivers. We suggest robust enrollee testing as well as formatting requirements. In recent CMS demonstrations, such as the Financial Alignment Initiative for dually eligible beneficiaries, we have seen first-hand the importance of beneficiary testing of notices and materials prior distribution.

As such, we strongly encourage CMS to ensure that all MA VBID-related materials are tested through beneficiary focus groups. At a minimum, we suggest that CMS engage with consumer advocacy groups who have experience developing and vetting these types of beneficiary communications. We also expect CMS will require all enrollee communications to be linguistically and culturally competent, and be available in alternative formats, such as Braille, CD, large-font print and sign language translation. As educational materials are developed, we also encourage CMS to actively engage SHIPs, and to make relevant information available through other channels, including Medicare.gov and the Medicare & You handbook.

Establish a clear strategy and requirements for health care provider education and outreach. We are concerned about the lack of detail included in the program announcement with regard to provider education. From an enrollee perspective, adequate provider education is just as important as enrollee outreach for ensuring a smooth programmatic rollout. We do not believe that cost-sharing alone is an appropriate trigger to steer beneficiary utilization. Medicare beneficiaries participate in a complex health care system, within which health care providers largely direct treatment decisions. For the proposed VBID model to be successful, it must include complementary educational initiatives for both beneficiaries and health care providers.

This requires targeted provider outreach that both explains the purpose of the VBID model, as well as addresses providers’ practical concerns. The VBID announcement does not include detailed information for or direction to participating plans about provider education, nor does it define CMS’ role in provider outreach. We suggest that provider outreach focus on contracting details and include a clear explanation of any new billing practices and procedures. We urge CMS to consider outreach to all Medicare providers who may interact with enrollees in the new VBID model.   Recent demonstrations underscore the importance of ensuring community-based service providers receive outreach and training about new health care systems, as these providers are often the trusted entities beneficiaries turn to with questions.

Continued Stakeholder Engagement

Finally, as the model is updated and revised, we strongly encourage CMS to actively solicit feedback from diverse stakeholders, including consumer advocacy organizations. Developing a model with this level of complexity necessitates an ongoing, structured stakeholder input process with genuine opportunities for beneficiaries, their caregivers, and their advocates to provide feedback on design and implementation issues. It is not sufficient to discuss the general outlines of a demonstration with stakeholders. Details matter and those details are found in documents—in notices, in contracts, in manuals. For stakeholder participation to be genuinely effective, key planning and operational documents must be available for stakeholder review and input.

We appreciate the emphasis in the model to collect and monitor plan data to protect against adverse implications for beneficiaries. As noted above, we request that CMS share this data with stakeholders, along with any other evaluation and oversight information, in a timely and transparent manner. Beneficiaries and other stakeholders, as well as regulators, need access both to evaluations and to the underlying data about demonstration results.

As the proposed announcement details an evaluation process, we encourage CMS to ensure that independent stakeholders have access to all the information that they need to independently evaluate the demonstration’s performance. Further, it is important that reporting schedules for key performance information are designed so that issues can be spotted early and mid-course corrections can be effectuated. As the VBID model is proposed as a demonstration, we expect CMS will continue to share information with stakeholders, and make necessary changes and improvements to the models based on stakeholder feedback. 

Conclusion

The Center greatly appreciates the opportunity to provide feedback on the proposed Medicare Advantage (MA) Value Based Insurance Design (VBID) demonstration model.  For further information please contact Center Senior Policy Attorney David Lipschutz, dlipschutz@medicareadvocacy.org.

Sincerely,

David Lipschutz
Center for Medicare Advocacy