JustCare

Tag: MedPAC

  • Republicans look to end Medicare Advantage overpayments

    Republicans look to end Medicare Advantage overpayments

    More members of Congress on both sides of the aisle are looking at ways to end massive overpayments to Medicare Advantage insurers as a means of reducing federal spending, reports Peter Sullivan for Axios. Ending these overpayments should not affect people’s Medicare benefits, it would simply put spending in Medicare Advantage for each enrollee on a par with spending in Traditional Medicare. In sharp contrast, cutting Medicaid benefits would likely cause tens of millions of Americans to become uninsured or underinsured.

  • Medicare Advantage networks can be narrow and harmful

    Medicare Advantage networks can be narrow and harmful

    If you’re in a Medicare Advantage plan or thinking of joining one, you should worry about two things: Whether you will get the Medicare benefits you are entitled to when you need costly care and whether you’ll be able to use the doctors and hospitals you want to use. Cheryl Clark reports for MedPage Today on a recent Medicare Payment Advisory Commission (MedPAC) meeting in which commissioners criticized the Medicare Advantage networks as ever-changing and often too narrow and harmful to enrollees.

    You can’t trust Medicare Advantage (MA) provider directories to list in-network providers accurately. A lot of the time, the listed physicians and hospitals are not, in fact, in network. They’ve left the network. Or, they leave the network midyear. It can hurt enrollees, who lose continuity of care and must scramble to find new providers.

    When you buy health insurance, you should be thinking not simply about now but about what could happen to you in the future. Literally anything. A car accident, a fall on ice, a cancer diagnosis, a stroke. You might be away from home. Will your care be covered the way you want it to be in a Medicare Advantage plan? What will you pay out of pocket?

    Here are some of problems you can face in any Medicare Advantage plan when it comes to getting a provider to deliver care. These problems don’t exist in traditional Medicare, the government-administered program that covers your care from almost any physician or hospital in the US:

    1. The Medicare Advantage plan can leave the Medicare program at the end of any year. And, many have done so in the last couple of years.
    2. Physicians and hospitals can leave the Medicare Advantage network. Your care is not covered if you keep seeing these providers. You can pay out of your own pocket to see them or you need to find new providers.
    3. In-network physicians might not be willing to see you. They might have too many patients already.
    4. Cancer centers of excellence and specialists you need to see might not be in-network.

    The Medicare Advantage network directories are very often out of date and inaccurate. Moreover, government oversight to ensure the adequacy of Medicare Advantage plan networks leaves a lot to be desired. Plans know that they can offer inadequate networks without accountability. The government has never penalized a Medicare Advantage plan for offering an inadequate network.

    There’s little good about Medicare Advantage networks in practice, though in theory they should help ensure you are getting good coordinated care. Unfortunately, the insurance companies offering Medicare Advantage make more money keeping you from getting good costly care. So, except for some of the nonprofit Medicare Advantage plans, Medicare Advantage insurers’ incentive is to delay and deny you care from good quality physicians and hospitals when you need them.

    Here’s more from Just Care:

  • Republicans and Democrats alike love social insurance, why shouldn’t we all benefit from it?

    Republicans and Democrats alike love social insurance, why shouldn’t we all benefit from it?

    An opinion piece in MarketWatch by Brett Arends, a financial writer, makes the seemingly obvious case that if Americans love Medicare, as they do, they love social insurance. Yet, they are not far-left commies nor do they hate freedom. Given the failure of for-profit health care, shouldn’t we all benefit from Medicare?

    The failure of for-profit healthcare: If you have any doubts, read this lead New York Times story on the psychiatric hospital chain that is locking up patients who do not need hospitalization in order to continue to reap revenue from insurers. While you’re at it, take a look at John Oliver’s piece on for-profit hospices. And, check out these blockbuster stories on Medicare Advantage cash monsters and how Medicare Advantage insurers gouge taxpayers.

    Make no mistake, the price we pay for having for-profit health insurance and for-profit hospitals and for-profit pharmaceutical companies setting drug prices is not only financial. Yes, the high costs bankrupt all too many Americans; they also keep us from getting needed care. The for-proft health care industry causes extraordinary physical and emotional harm. According to one analysis in the National Bureau of Economic Review, Medicare Advantage plans lead to tens of thousands of needless deaths of older adults and people with disabilities each year.

    The government is far from perfect. We all know how much harm it can do. But, at it’s best, unlike the for-profit health care companies, it works for the people. It puts patients first, not profits. And, even when the government is not working as well as it should for Americans, government-administered traditional Medicare delivers easy access to good affordable care at far lower cost than privatized for-profit insurance.

    As Arends says, “we are forced to confront some shocking details. Senior citizens are happier with their communist Medicare than the rest of us are with our “freedom” insurance from private companies.” He goes on with some compelling data:

    “A higher share of Medicare beneficiaries was satisfied with their ability to find healthcare providers who accepted their insurance (96%) compared with privately insured people (91%),” MedPAC reported. “In addition, among beneficiaries who had received healthcare, a higher share of Medicare beneficiaries was satisfied with their ability to find healthcare providers that had appointments when they needed them (87%) compared with privately insured people (77%),” it added.

    Furthermore, MedPAC said, “In our focus groups, Medicare beneficiaries also reported high satisfaction with their insurance coverage, with the vast majority of participants rating their coverage as ‘excellent’ or ‘good.’”

    Other polls show that 81% of Americans support Medicare, including not only 89% of Democrats but even 79% of Republicans!”

    Here’s more from Just Care:

  • Issues with network adequacy and prior authorization in Medicare Advantage persist

    Issues with network adequacy and prior authorization in Medicare Advantage persist

    MedPAC, the Medicare Payment Advisory Commission, just released a report focused in part on Medicare Advantage network adequacy and prior authorization issues. People enrolled in Medicare Advantage plans can find it challenging both to find health care providers who meet their health care needs and to get covered for the care their treating physician says they need. The Centers for Medicare and Medicaid Services (CMS) has taken some steps to address these issues, but there’s more to be done.

    Many hospitals and physician specialists say that some Medicare Advantage plans endanger patient health and well-being as a result of inadequate networks and non-evidence-based prior authorization requirements. In particular, many Medicare Advantage do not have cancer centers of excellence or mental health specialits in their networks. And, CMS only studies network adequacy at the “contract” level, meaning that it looks at an insurers’ entire network in an area, not at the networks of each individual Medicare Advantage plan the insurer offers.

    MedPAC explains in its report that in 2021, MA plans required prior authorization in 37.5 million instance, about 1.5 determinations for each enrollee. In the vast majority of cases, the MA plan covered the service. MedPAC does not address the consequences of delays in getting these determinations on patient health.

    In nearly two million cases–about five percent of the time–the MA plan denied coverage for the service requested. But, different MA plans had very different denial rates. Some denied coverage three percent of the time and some 12 percent of the time. Unfortunately, as of now, no one know which are denying 12 percent and which are denying 3 percent of requests, preventing individuals from distinguishing meaningfully among Medicare Advantage plans.

    The insurers offering Medicare Advantage profit significantly from denials. Most of the time, they are not appealed. Only 11 percent of denials are appealed, even though 80 percent of the time they are reversed on appeal.

    For sure, prior authorization costs hospitals and physicians a lot of time and money. To what extent is it keeping patients from getting necessary care or delaying critical care or creating a serious health risk?

    Even a small proportion of prior authorization denials amounts to a large number of denials. The vast majority are not challenged, often to the detriment of patients. The Office of Inspector General’s audits suggests that a large proportion of those denials should have been approved.

    Here’s more from Just Care:

  • What does the MedPAC chair really think about Medicare Advantage?

    What does the MedPAC chair really think about Medicare Advantage?

    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:

  • Medicare Advantage needs serious fixes; $88 billion in government overpayments must end

    Medicare Advantage needs serious fixes; $88 billion in government overpayments must end

    The Medicare Payment Advisory Commission (MedPAC), a non-partisan independent agency, last week projected $88 billion in government overpayments to Medicare Advantage in 2024 and debated the value of the program, reports Noah Tong for Fierce Healthcare. While the $88 billion projection is lower than other analysts’ projections, it is serious money that is threatening the solvency of the Medicare Trust fund, endangering the Medicare program writ large, and driving up everyone’s Medicare costs.

    One MedPAC commissioner thought the MedPAC report was “too negative.” In truth, it couldn’t be negative enough, given the mountains of evidence that the Medicare Advantage plans are not only wildly overcharging the federal government but engaged in widespread and persistent delays and denials of care, while failing to disclose critical data to allow analysts to assess the quality of their coverage. And, this MedPAC commissioner did say: “There are plenty of bad things definitely that need to be improved.:

    For its part, the “Better Medicare Alliance,” an advocacy organization funded by the insurers, tout the extra benefits they offer. But, these benefits, such as dental services, are often extremely limited and most people appear not to be helped by them. Before, they’re available only because of the $88 billion in overpayments the MA plans receive each year.

    Another MedPAC commissioner highlighted that only people who are quite ill have serious problems with Medicare Advantage. Of course, that’s the problem, since everyone in Medicare Advantage has the coverage because they could become seriously ill. They don’t need the coverage if they’re relatively healthy.

    People who are in need of care face prior authorization denials, or can’t find a specialist to see or can’t use a cancer center of excellence. People don’t think about these issues when they enroll in Medicare Advantage if they’re healthy. If they did, they would seriously consider enrolling in Traditional Medicare. Traditional Medicare has no insurer middleman second-guessing your treating physicians. Moreover, unlike Medicare Advantage, it covers your care from virtually all doctors and hospitals in the US without the need for prior authorization.

    One MedPAC commissioner nailed the problem, without agreeing with his own stated conclusions:  “What conclusion should I reach: that CMS leadership is unable to oversee the MA market, or that the recent and appropriate RADV audits are totally ineffective? In fact, CMS cannot oversee 4,000 plans all operating with proprietary administrative processes, failing to provide data they are required to disclose

    Gregory Poulsen, another MedPAC commissioner who is a senior vice president at Intermountain Healthcare, correctly pointed out that some MA plans do not add value and are not as good as others. Plans that are insurer-run, rather than physician/hospital run, tend to deliver poorer care which manage care to bring down spending. Some of the big insurers know how to maximize their revenue by gaming the payment system.

    Today, about half of people with Medicare are enrolled in a Medicare Advantage plan, most in a UnitedHealth plan or a Humana plan, possibly undercutting competition. The program in place to improve quality is a very expensive joke, failing to assess quality effectively.

    Lynn Barr, a MedPAC commissioner and founder of Caravan Health emphasized the excessive overpayments to Medicare Advantage. “I believe this is what the data shows. We have allowed MA to buy the market. That is why MA is growing. It’s not because the quality is so great. People don’t love the prior authorizations, people are leaving their plans a lot. This is not the big, lovely success everyone says it is. We continue to create policy that drives people into these plans.I think we’ve got do something to reduce these payments to MA.”

    Here’s more from Just Care:

  • AHA warns Medicare oversight agency about dangers of Medicare Advantage

    AHA warns Medicare oversight agency about dangers of Medicare Advantage

    In a letter to the Medicare Payment Advisory Commission (MedPAC), the American Hospital Association (AHA) expresses serious concerns about the dangers of Medicare Advantage, including the consequences of inappropriate coverage and payment denials and delays. MA is not delivering the health coverage people need; and, prior authorization requirements delay potentially life-saving time-sensitive treatments, such as cancer treatment regimens.

    The AHA explains that the insurers offering Medicare Advantage plans use prior authorization in ways that create “dangerous delays in care.” The AHA’s greatest concern is that MA plans use prior authorization to deny medically necessary care. To show clinical appropriateness, providers are required to spend an excessive amount of resources documenting the need, while patients’ care is delayed, to their detriment.

    The stories the AHA recounts of insurer MA bad acts are disturbing, appearing to put insurers’ profits ahead of patient needs: “For example, an AHA member indicated that a patient with traumatic brain injury was medically ready for discharge but stayed four additional days in the hospital without access to essential [post-acute care] because the insurer had not responded to the provider’s request to move the patient into a rehabilitation facility. Another AHA member … reports that 11% of their MA referrals take 10 days or longer to resolve. Furthermore, another AHA member reported that, in 2022, over 400 MA patients at its academic medical center had delayed discharges due to insurance issues, the vast majority of which were attributable to prior authorization delays, and the delays amounted to 1,233 avoidable inpatient days.”

    More than nine in 10 physicians report patient care delays because of prior authorization and one in three of them say that prior authorization resulted in a “serious adverse event for a patient in their care such as hospitalization or death.” Not only does the prior authorization process endanger the health and well-being of patients, it can be extremely burdensome for providers. Moreover, the process is not transparent or consistent across MA plans. Different rules for different plans and different electronic portals make it all the harder for providers to comply.

    MedPAC is an independent Congressional agency established to advise Congress on the Medicare program. MedPAC can write reports on MA issues, but it has no real authority to do anything. And, neither Congress nor the Centers for Medicare and Medicaid Services seem to respond in meaningful ways to MedPAC recommendations.

    Right now, the benefits of prior authorization appear more than outweighed by the harm to patients and the burdens on providers. That will continue so long as each insurer can develop its own proprietary prior authorization protocols. CMS should mandate that insurers all use one standardized set of public and medically justified prior authorization protocols and one standardized system for handling them. Without standardized and public prior authorization protocols, people cannot know whether the MA plan they enroll in will delay and deny their care excessively and inappropriately, as appears to be the case for people in UnitedHealth and Humana Medicare Advantage plans.

    Here’s more from Just Care:

  • The government overpays insurers offering Medicare Advantage as much as $140 billion in 2023

    The government overpays insurers offering Medicare Advantage as much as $140 billion in 2023

    A new report from Physicians for a National Health Plan (PNHP) reveals that the federal government is overpaying health insurance corporations offering Medicare Advantage plans as much as $140 billion in 2023. Matthew Cunningham-Cook and Lucy Dean Stockton report for Jacobin on PNHP’s report and the four ways the government overpays for Medicare Advantage at the same time that the Medicare Advantage plans engage in inappropriate delays and denials of care and coverage.

    The total annual Medicare Advantage overpayments would cover the full annual cost of part B premiums for everyone with Medicare, which usually is taken out of people’s Social Security checks. People with Medicare typically are left with about $1,600 in Social Security benefits. Not only are people with Medicare paying more than they should as a result of the Medicare Advantage program, the insurers offering Medicare Advantage plans, including UnitedHealthcare, Cigna and Humana, are “quietly plundering the the Medicare Trust Fund,” says Ed Weisbart, a physician who serves as PNHP’s secretary.

    With traditional Medicare, administrative costs are less than two percent and no one is profiting. With Medicare Advantage, insurers receive for each enrollee about 119 percent of what the government spends on enrollees in traditional Medicare because they are able to game the system.

    To be clear, Congress established Medicare Advantage, Part C of Medicare, arguing that it would save Medicare money. To the contrary, it has always cost more than traditional Medicare. The Medicare Advisory Payment Commission or MedPac has documented some of the overpayments.

    In short, the payment system to Medicare Advantage plans is defective, leading to gross overpayments. As bad, it makes it more profitable for the insurers offering Medicare Advantage to delay and deny care. The government pays them the same amount regardless of how much they spend on people’s care.

    Consequently, evidence abounds regarding people enrolled in Medicare Advantage who suffer and die prematurely because they are unable to get the care they need. They wait so long to get prior authorization from their Medicare Advantage plan that it is too late for them to get the treatment they need. Or, the Medicare Advantage plan denies them the needed treatment. Or, the Medicare Advantage plan has no top cancer providers in its network and they are either forced to get lower quality care or pay the full cost of care themselves.

    People are generally locked into their Medicare Advantage plans once they join, even though they are told that they can switch back to traditional Medicare each year during the open enrollment period. Because traditional Medicare does not have an out-of-pocket limit, they do not want to take the risk of signing up for it without also getting supplemental coverage to protect them from financial liability. But, insurers do not have to sell them this insurance except in limited situations after they first enroll in Medicare and, if the insurers are willing to sell them insurance, they can often charge astronomical prices for the coverage.

    In addition, hospitals and physicians can drop their contracts with Medicare Advantage plans as they will. And, they are doing so. The CEO of Scripps, a health system in California says: “We are a patient care organization and not a patient denial organization and, in many ways, the model of managed care has always been about denying or delaying care — at least economically.”

    Scripps is not alone. Throughout the country, in myriad states, including Ohio, Virginia, Oregon, Missouri, Oklahoma, and South Dakota, hospitals and physicians have pulled out of their Medicare Advantage contracts because of patient safety concerns, inappropriate denied claims and prior authorization headaches.

    How do Medicare Advantage plans profit so much?

    1. By marketing to and enrolling disproportionately more healthy people than traditional Medicare. Healthy people cost them very little, but the government still pays them around $12,000 for each healthy person. When people get sick and go without care because they can’t afford the copays in Medicare Advantage or can’t find a physician to provide them the care they need, the Medicare Advantage plans continue to profit. MedPAC says that Medicare Advantage plans receive about $44 billion to $56 billion more than they should as a result.
    2. By adding diagnoses codes to enrollee medical records, even when the enrollee is not getting more care, so that the government pays them more for these enrollees. This practice is called “upcoding.” And, it leads to $27 billion more in spending in 2023.
    3. By receiving bonuses for serving certain communities and based on quality benchmarks. But, neither are appropriate, according to MedPAC. Currently, Medicare provides bonuses to Medicare Advantage plans based on the locations they cover, supposedly to ensure equal geographic access to coverage. These overpayments total around $24 billion a year.
    4. By requiring their enrollees to pay part of the cost of their care each time they get care. Consequently, people in Medicare Advantage tend to forego care more often than people in traditional Medicare. The vast majority of people in traditional Medicare have supplemental coverage that relieves them of the need to pay anything beyond the cost of coverage for their care. So, people with traditional Medicare end up getting more care than people in Medicare Advantage, but the government pays Medicare Advantage plans as if their members get the same amount of care as people in traditional Medicare. This adds an additional $36 billion in overpayments.

    Here’s more from Just Care:

  • Would standardizing Medicare Advantage plans protect people from making a bad choice?

    Would standardizing Medicare Advantage plans protect people from making a bad choice?

    The Medicare Payment Advisory Commission, “MedPAC,” in its June 2023 report to Congress, makes the compelling case that the government should standardize Medicare Advantage plans. The MedPAC report underscores how difficult it is for people to choose among these health plans offered by corporate health insurers. But, standardization alone will not allow people to make a meaningful choice or to protect themselves against corporate health insurers that are bad actors.

    MedPAC does not explain that the Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicare, either does not have, or withholds, information about Medicare Advantage plans that people need in order to make an informed choice. MedPAC does not make the case that more information must be provided to people choosing a Medicare option. Without additional information on plan delay and denial rates, for example, it’s hard to imagine that people could make a meaningful choice.

    People enrolling in a Medicare Advantage plan today take a risk that they will end up in a plan that inappropriately delays and denies them the care they need, potentially endangering their health and well-being. According to the HHS Office of the Inspector General (OIG), some Medicare Advantage plans engage in widespread and persistent inappropriate delays and denials of care and coverage but CMS does not name these plans. Rather CMS’ star-rating system misleads people into believing that they will get the care they need in a Medicare Advantage plan with a four or five-star rating, even though those plans might be engaged in widespread inappropriate delays and denials of care.

    Right now, it is impossible for people to compare their Medicare Advantage options; they have 41 of them on average. Even the smartest people out there and the people most knowledgeable about Medicare Advantage can’t compare these plans in a meaningful way. People with cognitive impairments, low health literacy levels, or who speak English as a second language are at a total loss.

    Medicare Compare is the government tool designed to help people choose among Medicare Advantage plans. But, Medicare Compare doesn’t let you know which plans have the highest denial and delay rates, the highest mortality rates, the poorest provider networks and other telling quality measures. The most you know is whether a plan has a four or-five star rating, and the government gives out high ratings regardless of delay and denial and mortality rates.

    CMS needs to standardize benefits in Medicare Advantage plans and limit the choices available to people. Too much choice is confusing and unhelpful. CMS also needs to disclose in an easily accessible form information about the plans that are violating their contractual obligations and putting their enrollees’ health at risk, which CMS has so far failed to do.

    With the plans in the State Health Exchanges, CMS  offers four options, bronze, silver, gold and platinum. For each metal type, it standardizes the plan’s deductible, out-of-pocket limit, and cost sharing amount for most major service categories, including prescription drugs.

    Here’s more from Just Care:

  • Don’t assume a five-star Medicare Advantage plan will provide the care you need

    Don’t assume a five-star Medicare Advantage plan will provide the care you need

    Laura Beerman writes for Health Leaders on the flaws in the Medicare Advantage star-rating system. If you asked me, I’d tell you it’s a farce. The gaming that goes on to get four and five-star ratings is unacceptable. And, even with a five-star rating, the Medicare Advantage plan may be engaged in widespread and persistent delays and denials of care. Don’t assume a five-star Medicare Advantage plan will provide you with the care you need.

    You can’t know whether a particular Medicare Advantage plan will endanger your health if you need costly and complex care, in part because the government hides information about plans engaged in bad acts. While you should avoid Medicare Advantage plans that do not have four or five-star ratings, you are taking a huge gamble even if you sign up with Medicare Advantage plans that have four and five-star ratings. These ratings do not reflect whether you will be covered for care from top flight doctors and hospitals or how much hassle you will face getting the care you need. And, that’s what you should care about when choosing a Medicare Advantage plan.

    The health insurers offering Medicare Advantage tend to love the star-rating program. If they can get the stars, they earn huge additional revenue from the government. And, believe it or not, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare Advantage, allows the insurers to bundle together several Medicare Advantage plans when applying for star-ratings. So, if one Medicare Advantage plan performs poorly based on the measures CMS uses to give stars, it can still “look” good in terms of the number of stars it has.

    If you don’t believe me, just read this piece by two former leaders at CMS: The Emperor Has No Clothes: “[T]he Five-Star program, while well intended, primarily creates a ‘performing to the test’ result rather than solid and important quality improvements in outcomes.”

    In fairness, CMS has gotten a bit tougher in its standards for doling out five and four-star ratings to Medicare Advantage and Part D prescription drug plans. But, not nearly tough enough. Nor has CMS created standards that would actually reflect whether a Medicare Advantage or Part D plan is engaged in massive inappropriate delays and denials of care and coverage or does a good job of managing your care. More than half of all Medicare Advantage plans in 2023 had a four or five-star rating!

    Alignment Health, Elevance Health, Humana, and UnitedHealthGroup all received four or five-stars for their Medicare Advantage plans, as did Kaiser Permanente. Again, don’t assume much positive about these plans when it comes to whether they are covering their enrollees’ care as required under their contracts.

    Aetna Medicare Advantage plans fared worse than others with only 21 percent of its Medicare Advantage plans receiving four or five-star ratings. Should you avoid Aetna Medicare Advantage plans with three-star ratings? It’s not clear, but probably. They are being paid as much as $1 billion less in 2024 because of the lost stars, which means they will have less money to spend on your care.

    MedPAC, the independent agency that oversees Medicare Advantage quality, has said several times in its annual report to Congress: “[T]he Commission has been increasingly concerned that Medicare’s approach to quality measurement is flawed because it relies on too many clinical process measures.” In 2023: “Over the years, the Commission has determined that the QBP [Quality Bonus Program] is flawed and does not provide a reliable basis for evaluating quality across MA plans in meaningful ways…”

    Here’s more from Just Care: