Medicare Advantage needs an overhaul

Researchers enlisted 39 “experts” to identify reforms to Medicare Advantage. In a Health Affairs piece, the researchers report that the experts–including consumer advocates, policymakers, and industry leaders–agreed on six policy ideas to “help” people enrolled in a Medicare Advantage plan. Sadly, these ideas would still leave in place Medicare Advantage plans with the power and incentive to endanger enrollees’ health and lives in order to maximize profits and people unable to know how to avoid the bad actors. For that, Medicare Advantage would need an overhaul.

The six ideas would, at best, be of minor benefit to people enrolling in Medicare Advantage. They would not help people choose a good health plan, nor would they save them money. Curiously, the experts appear to overlook the biggest ideas, including:

1. Requiring an independent agency to process all Medicare Advantage claims and use standardized prior authorization protocols. This would help ensure that Medicare Advantage plans covered the same services and did not deny or delay care inappropriately.

2. Requiring complete, accurate and timely claims and encounter data, as well as denial and appeal overturn rates from each plan, available for analysis and public reporting. This would help people distinguish in meaningful ways among Medicare Advantage plans.

3. Requiring adequate resources for CMS oversight of Medicare Advantage plans and meaningful penalties to impose on plans that do not comply with their contractual and legal obligations.

Here are the proposed reforms and why they would be of little if any benefit:

Standardizing supplemental benefits: Yes, it is true that people have no way to compare supplemental Medicare Advantage benefits; each Medicare Advantage plan offers something different. But, what is also true is there is no way to compare medical and hospital benefits and they are far more consequential to people enrolled in Medicare Advantage plans. Each Medicare Advantage plan relies on different prior authorization rules for determining whether to cover a given service. And, many of them, if not most, engage in widespread and persistent inappropriate delays and denials of coverage. How can people meaningfully compare plans that do not abide by the same coverage rules?
Limiting the number of Medicare Advantage plans that an insurer can offer. Yes, it is true that the plethora of Medicare Advantage plan choices only adds to people’s confusion. People need one choice of a good health plan; and, they have no way of knowing whether a good health plan choice is available to them.
Reforming agent commissions. Yes, Medicare Advantage insurers can and do often pay sales agents higher commissions to steer people to their most profitable Medicare Advantage plans, even if those plans are not the best for the enrollees. But, again, if the plans the agents are offering will not meet people’s needs–and we don’t know whether they will or not because the data is unavailable–reforming agent commissions will be of little help to people with Medicare.
Utilization management standards. If this means requiring Medicare Advantage plans to use the same prior authorization rules for determining whether care is covered, that would be beneficial. It is not clear though whether this proposal would standardize all coverage rules, which is what is needed so that people could make apples to apples comparisons of their coverage in different Medicare Advantage plans.
Network standards. If this means ensuring that all enrollees have access to top specialists and specialty hospitals, that would be beneficial. But, it does not. People should not be misled into signing up for Medicare Advantage plans that have “ghost” networks that make it challenging, if not impossible, for them to get their care covered from an in-network provider.
Increase competition between traditional Medicare and Medicare Advantage. If this were to mean adding an out-of-pocket cap to traditional Medicare, that would be a step forward and give people a meaningful choice of traditional Medicare. Traditional Medicare covers all medically reasonable and necessary care from most hospitals and physicians across the US. Today, traditional Medicare lacks an out-of-pocket cap, so many people find traditional Medicare unaffordable; they need supplemental coverage to protect themselves from catastrophic costs.

Here’s more from Just Care:

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