As a new session of Congress has begun, and a new Administration begins in a matter of days, it is time to expand on important oversight and consumer protection measures surrounding Medicare Advantage (MA) plans. Over the last 4 years, progress has been made in trying to rein in wasteful MA overpayments, curb plans’ inappropriate use of prior authorization, and other measures – but much more still needs to be done.
A recent Kiplinger article titled “Problems with Medicare Advantage Plans Keep Mounting” by Elaine Silvestrini (Jan. 4, 2025), which quotes the Center for Medicare Advocacy, summarizes some of the pros and cons of MA plans, and states: “While most enrollees are satisfied with their plans, MA faces mounting criticism for denying and delaying some needed care while costing taxpayers billions more than government-run, so-called fee-for-service, traditional Medicare.”
With respect to denials and delays in care, recent efforts by the Centers for Medicare & Medicaid Services (CMS) to rein in abusive prior authorization practices employed by Medicare Advantage plans have been welcomed by advocates and providers alike. But there remain significant shortcomings that must be addressed. As noted in a recent MedPage Today article titled “Do the New CMS Rules on Prior Authorization Go Far Enough?” by Joyce Frieden (Jan. 7, 2025), provider associations such as the American Medical Association (AMA) remain frustrated. The article states:
The AMA agrees that prior authorization is still a big problem, AMA President Bruce Scott, MD, said in a phone interview […] “I think there’s a growing awareness across health systems that [prior authorization] is overused, unjustified, and needs to be right-sized,” he said. “Patients are becoming increasingly aware of this overused blunt cost-control process by insurance companies. As a result, there is anger that’s building and frustration among physicians that has grown as well.”
As noted in a previous CMA Alert titled “Senate Subcommittee Report Details Medicare Advantage Coverage Denials” (Oct. 24, 2024), in October 2024 Senator Richard Blumenthal (D-CT), Chair of the U.S. Senate Permanent Subcommittee on Investigations, released a 54-page report regarding its ongoing investigation of Medicare Advantage plans’ Prior Authorization and on-going denials. The report highlights how three major insurers: UnitedHealthcare, Humana, and CVS “intentionally use prior authorization to boost profits by denying post-acute care.”
Many of the denials analyzed by the committee increasingly rely on artificial intelligence (AI), not health care experts, to make coverage decisions. As discussed in another CMA Alert titled “Lawmakers Urge CMS to Increase Oversight of Medicare Advantage Plans’ Use of AI and Algorithms in Making Coverage Decisions” (July 3, 2024), a number of legislators have outlined steps CMS should take in order to better protect MA enrollees and hold plans accountable.
Last month, the House of Representatives released a report titled “Bipartisan House Task Force Report on Artificial Intelligence” (Dec. 2024); also see Speaker Johnson’s press release (Dec. 17, 2024). In an analysis of the use of AI to make “Health Insurance Decisions,” the report talks about some of the promise of AI use in healthcare, but then states:
However, stakeholders have criticized the implementation of AI tools by health insurers for insurance decisions for a lack of transparency in coverage decisions. While Medicare Advantage insurers have flexibility in Medicare benefit design, questions have been raised about the use of AI systems created to predict estimated lengths of stay based on statistical metrics and then rejecting patient requests for care that exceeded this length, even if supported by caregiver opinion.[…]
There is potential to use AI as a medical management tool in some instances, but there are concerns that these applications could create unnecessary denials and lack of access to necessary treatments when AI produces inaccurate or biased results.
Ensuring adequate access to care, free from inappropriate use of prior authorization (whether using AI or not), is not a partisan issue. Neither is the topic of wasteful government spending, including Medicare Advantage overpayments. The Wall Street Journal, which defines its news mission to be “the definitive source of news and information through the lens of business, finance, economics and money, global forces that shape the world and are key to understanding it” has run a series of articles about how UnitedHealth, the largest Medicare Advantage insurer, maximizes its revenue of federal tax dollars, often through questionable means (see, e.g., this CMA Alert (Aug. 8, 2024)).
Most recently, the Journal published an article titled “UnitedHealth’s Army of Doctors Helped It Collect Billions More From Medicare” by Christopher Weaver, Anna Wilde Mathews and Tom McGinty (Dec. 29, 2024), which discusses risk-adjusted payment to plans based, in part, on health conditions collected and reported by the plan. The Journal’s “analysis found sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra government payments to insurers […] Patients examined by doctors working for UnitedHealth … had some of the biggest increases in sickness scores after moving from traditional Medicare to the company’s plans,” increasing 55% on average, generating an additional $4.6 billion from 2019 to 2022 compared to what the company would have received if such scores had matched industry averages.
Conclusion
Regardless of who is running the Medicare program or the government, Medicare beneficiaries and taxpayers in general deserve a program that provides necessary care without exorbitant and wasteful costs. As quoted in the Kiplinger article referenced above, Senator Blumenthal “says reforming Medicare Advantage is a bipartisan issue because the people affected belong to both parties. While he says he thinks general Medicare should be expanded to provide better coverage, he adds that’s no excuse for failing to reform Medicare Advantage.” We agree.
January 9, 2025 – D. Lipschutz