Over the last several weeks, the Commonwealth Fund, a private foundation with a mission “to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable”, has posted a series of blogs focusing on different aspects of the Medicare Advantage (MA) program: Payment, Risk Adjustment, Choice, Quality, Special Needs Plans and Benefit Design.
One of the most recent posts, for which the Center for Medicare Advocacy was consulted, is titled Taking Stock of Medicare Advantage: Benefit Design (March 31, 2022). While this blog series draws from a number of perspectives about the MA program, including those with which we disagree, they touch on many issues that the Center for Medicare Advocacy has been highlighting, including:
- Payments – “Among the experts we spoke with, there was broad consensus that the payment system creates inefficiencies. While there was less agreement on how to fix it, many pointed to policy changes that could make the payment system more equitable and competitive.”
- Risk Adjustment – Noting that “payments to Medicare Advantage plans continue to be above what CMS spends on comparable beneficiaries in traditional Medicare,” the post includes an examination of “whether the current system fuels overpayments to plans or encourages plans to enroll certain beneficiaries but not others and, if so, what policy changes may be needed to remedy these problems.”
- Choice – “The health economists and Medicare experts we spoke with said choosing among plans can be difficult, even for the savviest consumers.” Further, “the experts agreed that most beneficiaries aren’t making informed or active decisions. Instead, many choose plans based on advertising, word-of-mouth, or brand loyalty, then stay with those plans year after year, even if another plan would better serve their interests.” Among potential remedies, “States or the federal government could substantially enhance beneficiary choice by requiring insurers that sell Medigap policies.”
- Quality – “The quality bonus program in Medicare Advantage is expensive. Since 2015, it has paid out $47.5 billion in additional plan payments, offsetting cuts imposed by the Affordable Care Act.” Further, “Several of the experts we spoke with consider the quality bonuses unjustifiably expensive and ineffective.” In addressing the question “How does Medicare Advantage compare to the traditional, fee-for-service program when it comes to quality of care?” several research topics were proposed, including “the factors driving disenrollment from Medicare Advantage plans as patients become sicker, and how plans’ prior-authorization requirements affect quality of care.”
- Special Needs Plans – “Most of the experts viewed SNPs as a good platform for tailoring care to people’s needs” but they “also agreed not enough is known about whether and how SNPs are customizing care” and that “[m]ore should be done to assess the impact of SNPs on beneficiaries’ health.”
- Benefit Design – Because of flexibility given to MA plans with respect to the type of supplemental benefits they offer and to whom, “determining which plans offer which supplemental benefits and to whom is not easy.” Further, “Despite the out-of-pocket cap, Medicare Advantage enrollees may be exposed to higher costs than in traditional Medicare (e.g., during an extended hospital stay). These costs may not be anticipated or easily determined when enrolling in a Medicare Advantage plan. Some experts wanted to see more standardization in cost-sharing methods to help beneficiaries sort through plan options.” In addition, “Some experts raised concerns about the ubiquity of prior authorization requests, noting they are increasing as more people enroll in Medicare Advantage and are now used even for low-cost services like transportation to medical appointments. […] A related concern is that plans are using proprietary, algorithm–driven systems to make decisions (including those requiring prior authorization) about approving coverage for services. Some experts wanted to see more regulation — if not an outright ban — on such systems until their validity is established.”