In an interview with Cheryl Clark, MedPage Today, Michael Chernew, Harvard University professor and chair of the Medicare Payment Advisory Commission or MedPAC, leaves you wondering what he really thinks about Medicare Advantage, failing to answer simple questions about major concerns with Medicare Advantage. Chernew eventually concedes that people do not have the information they need to distinguish among Medicare Advantage plans and that some Medicare Advantage plans are not covering care people need. He also eventually agrees that we can improve the fiscal solvency of the Medicare program by cutting MA payments.
Initially in response to questions about tens of billions of dollars in overpayments and widespread and persistent wrongful care denials in Medicare Advantage, Chernew demurs, as if these are not serious concerns.
Anyone who is interested in reforming Medicare Advantage should read the full interview. Here are some highlights:
Chernew acknowledges that people cannot meaningfully choose among Medicare Advantage plans, saying “systems are hard to compare.” “The concern that “when you have a bunch of competing health plans, some of them may be doing things that you would rather them not be doing, and that their beneficiaries may not be aware of , is a real concern.”
But, Chernew won’t acknowledge that the MA market is broken. Rather, shockingly, he asks “how do you balance [government] oversight with allowing the market to actually work?” What’s astonishing is that Chernew seems to assume the market is working. Best I can infer is that he thinks it’s working because so many people are enrolled in MA plans.
Yet, if the MA plans are wildly overpaid and the data is not available to assess MA plan quality, as MedPAC has said year in and year out, how can Chernew suggest the market is working? The Centers for Medicare and Medicaid Services (CMS) doesn’t begin to have the data it would need to assess MA plan quality. Neither CMS nor MedPAC can conduct meaningful oversight of MA plans. CMS struggles to identify the bad actors and hold the plans to account for their bad acts.
On the question of waste in Medicare Advantage–$88 billion in projected overpayments this year alone, according to MedPAC–Chernew focuses on “efficiency.” If I am reading him correctly, efficiency as he sees it means spending less on care regardless of whether that is leading to good health outcomes. The data indicate that MA plans spend around 20 percent less on Medicare benefits than Traditional Medicare.
Chernew also doesn’t acknowledge that every year since its inception Medicare Advantage has cost more per enrollee than Traditional Medicare, meaning that MA is far less cost-effective than TM, as MedPAC has said.
Clark says: We are seeing a lot of waste in Medicare Advantage. And, the insurers offering these plans are powerful, driven by profits first and foremost. At the same time, many hospitals and physicians are not accepting Medicare Advantage because MA plans undermine access to care and inappropriately deny care.
Rather than responding to the massive waste in Medicare Advantage, Chernew’s response focuses on “efficiency” and “care coordination” in Medicare Advantage. Where’s the evidence? If “efficiency” means delivering less care, that is true, but that is not good if that means denying people coverage for critical care. And, the Office of the Inspector General has twice reported on “widespread and persistent” inappropriate delays and denials of care in Medicare Advantage. Moreover, the vast majority of MA plans show little, if any, evidence of meaningful care coordination.
Chernew’s response also focuses on MA’s ability to focus on the “whole patient.” That might be true in theory. But, where is the evidence for that?
Chernew lastly mentions additional benefits in MA. He suggests that MA plans have lower out-of-pocket costs than TM. That is true only in some cases, according to the Kaiser Family Foundation, Overall, people in Traditional Medicare have fewer cost barriers to care than people in MA. And, people with low incomes and people of color experience serious cost barriers to care in MA.
There’s substantial evidence that many MA plans offer extra benefits as a marketing tool. They lure people to enroll but, in fact, these benefits can be extremely limited and come with high out-of-pocket costs so they go unused. The data to do a thorough assessment is lacking. But, if these extra benefits come at the price of inadequate or unaffordable medical and hospital coverage, are they worth it?
Clark asks: Do you believe Medicare Advantage is working as intended? To this question, Chernew again focuses on “efficiencies” in MA, likely meaning coverage of fewer health care services, as if that is an achievement, again without acknowledging the mountains of evidence that many MA plans deny their enrollees medically necessary care when they most need it. The Kaiser Family Foundation has a different take you can read here.
Chernew recognizes that you could “improve the balance of payments” to Medicare Advantage plans, without acknowledging how or the political challenges. He also does not mention that the tens of billions of dollars in overpayments to MA plans threaten Medicare’s sustainability and drive up Medicare Part B premiums for everyone.
Clark asks a follow-up question: How do we stop the “upcoding” in Medicare Advantage that drives up costs inappropriately and excessively? Chernew admits to some coding fraud by insurers but suggests that most of the upcoding is accurate. The issue is that coding in traditional Medicare is not accurate. Again, he is silent on the issue of massive overpayments in MA as a result of the system for determining payments to MA plans.
Moreover, there’s compelling evidence that MA plans do not do a better job of treating people with chronic conditions, but Chernew disregards this evidence. Meanwhile, MedPAC has said repeatedly that the evidence is not available to assess MA plan quality.
Clark follows up with the issue of network inadequacy in some, if not many, MA plans. She says that MA plans often do not cover care from centers of excellence and other top health care providers. Chernew again does not appear concerned. Chernew “has a hard time seeing how one accomplishes what one wants to accomplish In Medicare Advantage if one requires all the academic medical centers to be in network…” What exactly is Chernew looking to accomplish with Medicare Advantage? Chernew suggests that MA is accomplishing something positive when the available data show that many, if not most, plans do not deliver value. How is it good that people can’t see top quality providers in most MA plans and taxpayers spend more on these plans per person than Traditional Medicare?
Chernew recognizes that people cannot switch out of MA to Traditional Medicare with a Medigap because insurers do not have to sell them coverage. Chernew does not like the idea of people switching out of MA when they get sick. He does not address the fact that they do so because they can’t get the care they need in MA.
Chernew does not believe that MA offers lower quality care than TM, notwithstanding the mountains of evidence of poor quality in some MA plans or the fact that MedPAC has never been able to assess quality because the evidence is not available.
When Clark asks about harm to MA enrollees stemming from the lack of continuity of care in MA because many providers cancel their MA contracts, Chernew acknowledges this problem. But, he claims, again without evidence, that “MA plans rely on networks to accomplish what they need to do, and on balance that’s probably a good thing but it makes choice complicated.“ How can this be a good thing?
On the issue of misleading marketing, Chernew admits “The plans are just so complicated and so varied, there may be value in some type of standardizing benefits. It’s hard to make sure everybody gets the information they need.” There “may be value?” You have to wonder about whether Chernew is truly an independent expert or beholden to industry.
When Clark pushes Chernew on the value of MA over Traditional Medicare by stating that physicians who know how MA works never enroll in an MA plan when they retire, Chernew demurs, saying he has not “studied the issue thoroughly.”
When Clark again asks about MA plans wrongfully denying care, Chernew finally admits to the problems with prior authorization and inadequate networks in MA. “Patients are not getting the care they need and their experiences are atrocious.” But, for reasons that are unclear, he seems to suggest these are exceptional problems.
In her last question, Clark asks Chernew whether we can improve the fiscal solvency of the Medicare program by cutting MA? Chernew here says, absolutely, yes! Finally, he admits that MA overpayments are undermining Medicare.
Here’s more from Just Care:
