Government is not warning people about Medicare Advantage plans that could endanger their lives

Some Medicare Advantage plans are denying care inappropriately, endangering the lives of tens of thousands of people with Medicare. And, the government isn’t warning people about these Medicare Advantage plans. Instead of holding Medicare Advantage plans accountable for their bad (and sometimes deadly) acts, the government is protecting Medicare Advantage plans, at the cost of hurting the older adults and people with disabilities who are enrolled in them.

Medicare Advantage plans have a powerful financial incentive to delay and deny needed care that appears too great to resist, at least for some. Paying Medicare Advantage plans a capitated fee–a fixed monthly amount unrelated to the cost of services delivered–provides Medicare Advantage plans with the ability to profit wildly from delaying and denying care. And, that’s what is happening with, at least, some Medicare Advantage plans,

What we know:

American Hospital Association (AHA): “Inappropriate and excessive denials for prior authorization and coverage of medically necessary services is a pervasive problem among certain plans in the MA program.” AHA “urges CMS to take swift action to hold Medicare Advantage (MA) plans accountable for inappropriately and illegally restricting beneficiary access to medically necessary care.”

American Medical Association poll: More than one in four (28%) physicians believe that prior authorization rules for some tests and treatments are harming patients.  Some health plans have prior authorization rules that are out of sync with standard medical practice.

HHS Office of the Inspector General (OIG) report:

• Some Medicare Advantage plans are inappropriately denying potentially life-saving care to tens of thousands of older adults and people with disabilities—care that traditional Medicare covers, including rehab services, care in skilled nursing facilities, MRIs and other costly tests.
• Nearly one in seven (13%) Medicare Advantage plan denials of care are wrongful.
• An OIG 2018 report raises equally troubling concerns about the risks faced by older adults and people with disabilities in Medicare Advantage.

National Bureau of Economic Research report: Medicare would save “around ten thousand” lives a year if CMS cancelled contracts with the bottom-ranking five percent of Medicare Advantage plans and randomly reassigned their enrollees to other Medicare Advantage plans.

What is to be done?

OIG recommendation: CMS should protect people with Medicare and provide them “with clear, easily accessible information about serious [Medicare Advantage] violations.”

AHA recommendation: Public reporting of data on delays and denials of care at the plan-level.

People with Medicare need to know which Medicare Advantage plans are the bad actors

• CMS must warn people enrolled in Medicare Advantage plans about serious violations.
• CMS should meaningfully hold the bad Medicare Advantage actors to account, cancelling their contracts when necessary to protect people with Medicare and ensuring people in these plans can switch to traditional Medicare if they want to.
• CMS should not give Medicare Advantage plans an 8.5 percent rate increase next year. It should be prohibited from paying them more per enrollee than it spends on people in traditional Medicare.

Here’s more from Just Care:

• How Connecticut Eliminated Capitated Managed Care in Medicaid
• AHA underscores dangers of Medicare Advantage, need for greater accountability
• Prior authorization in Medicare Advantage harms patients, sometimes severely
• OIG finds widespread inappropriate care denials in Medicare Advantage
• One in four Medicare Advantage plans engage in misleading marketing