JustCare

Tag: Accountability

  • To protect older adults and people with disabilities, Congress must add an out-of-pocket cap to Traditional Medicare

    To protect older adults and people with disabilities, Congress must add an out-of-pocket cap to Traditional Medicare

    To promote health equity, meaningful choice, competition between Traditional Medicare and Medicare Advantage plans, as well as to protect older adults and people with disabilities, Congress should limit people’s out-of-pocket expenses in Traditional Medicare by adding an out-of-pocket cap. Congress also should eliminate the enormous overpayments to Traditional Medicare in order to ensure the sustainability of the Medicare Trust Fund and bring down Part B premiums.

    Health equity:  People of color and people with limited means are usually forced to choose among Medicare Advantage plans without being able to know which will cover their care appropriately. They are at serious risk. They are often locked into Medicare Advantage plans with very narrow networks and excessive prior authorization requirements because Traditional Medicare does not have an out-of-pocket limit and they cannot afford supplemental coverage.

    Medicare Advantage insurers are able to decide which Medicare Advantage plans offer more or fewer prior authorization requirements and better provider networks; but, there’s no way for consumers to know. The Medicare Advantage star-rating system is a farce; five-star plans can be bad actors, with ghost networks and widespread inappropriate delays and denials of care. The Centers for Medicare and Medicaid Services (CMS) has no way to protect vulnerable Medicare Advantage enrollees. Without an out-of-pocket cap in Traditional Medicare, they generally do not have it as an option.

    Choice: An out-of-pocket cap in Traditional Medicare would give people a meaningful choice of Traditional Medicare. It would allow people to enroll in Traditional Medicare without financial risk. Low and middle-income people and people of color lack this choice today because they cannot get the supplemental coverage they need to protect themselves financially. Supplemental coverage is either unaffordable or unavailable. 

    Indeed, today, people living in communities that insurers do not see as profitable, typically lower-income communities, can be left without any MA plan options and no meaningful Traditional Medicare option.

    Competition: An out-of-pocket cap would help level the playing field between Traditional Medicare and Medicare Advantage, driving competition.

    Cost savings: In 2024, Medicare Advantage plans cost as much as 22 percent more per person than Traditional Medicare, eating into the Medicare Trust Fund and driving up Part B premiums. Traditional Medicare is far more cost-effective than Medicare Advantage. An out-of-pocket cap in Traditional Medicare would enable more people to enroll, reducing Medicare spending.  

    Coverage: An out-of-pocket cap would protect people in Medicare Advantage plans who are too often inappropriately denied the reasonable and necessary services to which they are entitled. It would enable them to switch to Traditional Medicare. Today, the government cannot protect them from bad actor Medicare Advantage plans. The most vulnerable Medicare subpopulations are hardest pressed to navigate the rules and narrow networks in Medicare Advantage and get the care they need. 

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  • Five concerning policy outcomes of Medicare Advantage program

    Five concerning policy outcomes of Medicare Advantage program

    We frequently think about aspects of Medicare and MA in isolation from their effects on our healthcare system. But when we step back, we see the following Medicare Advantage policy outcomes that we would never choose to accomplish on a stand-alone basis.

    1. Medicare Advantage program incentivizes insurer competition around attracting healthy people and avoiding people with costly conditions—with networks that avoid top specialists and specialty hospitals, with coverage protocols that delay and deny care inappropriately—increasing costs for providers and patients in the system and maximizing profits for insurers.
    2. Medicare Advantage program is effectively unaccountable, operating largely on trust, with no real-time oversight or meaningful enforcement, which prevents people from knowing which MA plans will provide high value care if they have cancer or heart disease and which to avoid, forcing them to gamble when they choose an MA plan and leading more than 10,000 people to die needlessly each year when they choose the wrong MA plan.
    3. Medicare Advantage program misleads people, particularly those with low incomes, into believing that they will get the same benefits as people in traditional Medicare with an out-of-pocket cap, when insurers can game Medicare coverage requirements so as not to deliver the same benefits. In fact, mounting evidence indicates insurers too often inappropriately deny critical care and provider payments, threatening the health and financial security of the most vulnerable enrollees with complex conditions.
    4. Medicare Advantage program uses a payment system that insurers can game to achieve 23 percent more per enrollee than the government spends on enrollees in traditional Medicare, driving up Medicare spending and Medicare premiums by $260 billion in the 10 years ending in 2033, and threatening the Medicare program. And, while MA offers a valuable out-of-pocket cap to people with low incomes and “extra” benefits, unlike TM, when they get sick, they are often faced with financial and administrative barriers to care wealthier people in TM do not face, which aggravate health inequities.
    5. Medicare Advantage program is financially unsustainable over the middle to long term and, left to its own devices, likely will lead to the withering away of traditional Medicare, the end of Medicare negotiated rates as providers acquire more leverage over insurers, greater financial and administrative barriers to care and much higher costs for enrollees with costly conditions.

    Here’s what MA policy should be designed to do:

    • MA policy should incentivize MA plans to compete to deliver high value care to the people with complex and costly conditions.
    • MA policy should bar bad actors from participating in the program; at the very least, it should identify the bad actors so that people can avoid enrolling in them.
    • MA policy should ensure that MA enrollees get the same benefits as people in Traditional Medicare and that providers are paid appropriately for the care they deliver.
    • MA policy should ensure that insurer administrative costs and profits total no more than 15 percent more than insurers spend on care.
    • MA policy should not allow the MA program to cost any more per enrollee than Traditional Medicare.

    Here’s more from Just Care:

  • Medicare Advantage plans fail to release data required for oversight

    Medicare Advantage plans fail to release data required for oversight

    A recent MedPac presentation details several glaring issues with Medicare Advantage, of which both Congress and all Medicare Advantage enrollees should take careful note. MedPac cannot assess quality of care in Medicare Advantage, the private health plans that cover care for about half of all people with Medicare. The Medicare Advantage plans are not releasing complete and accurate data to enable appropriate oversight, nor is the Centers for Medicare and Medicaid Services (CMS) holding them accountable for failing to do so.

    Medicare Advantage plans have failed to disclose complete and accurate data, as they have been required to do, for the last 10 years. Encounter data shows the services people are receiving. And, it is needed for MedPac, the agency that oversees Medicare payments, to assess MA plan quality. According to MedPac, the Medicare Advantage quality data available is not meaningful.

    CMS, which oversees Medicare Advantage (MA) plans, has not held MA plans accountable for failing to disclose this data. Consequently, MA plans have little incentive to provide complete and meaningful encounter data. MedPac has spelled out what CMS should do, but CMS has not acted to create the appropriate incentives.

    Medicare Advantage plans claim to spend $50 billion on additional benefits for their enrollees in 2021, but there is no good information on how that money is spent. Rather, we know that too often these additional benefits come with high out-of-pocket costs and can be difficult to access.

    MedPac recommends that CMS withhold payments to Medicare Advantage plans that do not release complete and accurate encounter data so that they have an incentive to do so. Alternatively, if necessary, Medicare should require Medicare Advantage providers to submit their claims data to an intermediary, who could then ensure it was complete and accurate.

    In 2021, Medicare Advantage plans received $350 billion dollars from CMS. It boggles the mind that the government has little reliable data on how Medicare Advantage plans are spending that money and enrollees know so little about the quality of care they offer

    Here’s more from Just Care:

  • Biden administration proposes greater accountability from Medicare Advantage

    Biden administration proposes greater accountability from Medicare Advantage

    For years, the federal government has paid Medicare Advantage plans and Part D prescription drug plans hundreds of billions of dollars to cover Medicare benefits, demanding little transparency and accountability regarding the amounts they spend on medical care and drugs and the quality of coverage they provide. HealthcareDive reports that the Biden administration has issued a proposed rule that, if finalized, would demand greater transparency and accountability from Medicare Advantage and Part D plans. But, it’s hard to imagine it’s enough to ensure these corporate health plans cover the care people need.

    If you are enrolled in a Medicare Advantage plan and you develop a serious condition, you might find unwarranted and inappropriate delays and denials of care. Please let us know if you do. And, fight back. Appeal the denials. It’s easy. Medicare Advantage plans are obligated to cover all reasonable and necessary care, and the vast majority of denials are overturned on appeal.

    The challenge is that Medicare Advantage plans can be engaged in all sorts of behaviors that are harmful to their enrollees and difficult, if even possible, to detect.

    For example, MA and Part D plans sold in the individual market are charging their enrollees (27 million and 24 million respectively) copays based on their negotiated drug prices at pharmacies, even though these plans sometimes pay pharmacies lower rates. The proposed rule would require the Medicare Advantage and Part D plans to disclose those lower prices and pass their savings along to their enrollees through lower copays.

    The proposed rule also recognizes the dangers of deceptive marketing by Medicare Advantage plans and the third parties they hire to get people to join their health plans. It aims to do a better job of protecting people. Nice to hear, but it’s hard to see how that’s possible. Scammers abound.

    The proposed rule is intended to require MA plans to behave in compliance with their legal obligations in disasters and emergencies. During COVID, many MA plans were slow to advise their enrollees that referral and network coverage requirements are waived, as required.  It’s a bit Orwellian that the proposal requires private MA plans to comply with requirements already in place.

    MA and Part D plans would also be required to disclose more information about their networks and how they report medical expenses. But, already these plans face requirements to disclose data that they have never disclosed completely or accurately, according to MedPac, the agency that oversees them. And, even if it appears they have an adequate network, who’s to know if the providers they list are seeing more than a handful of new patients.

    The proposed rule would enable CMS  to keep MA plans that have performed poorly in the past–which ones are those, you might ask–from growing their MA plans. CMS has always had tools to penalize plans. But, the punishment never fits the crime. And, of course, there is little if any way for CMS to protect all the enrollees already in the MA plan.

    So while the proposed rule sounds great in theory, it’s hard to see how it will lead to lower costs or better quality of care. How exactly will CMS hold MA plans to these new standards? What’s the punishment if they don’t comply?

    Here’s more from Just Care: