JustCare

Tag: Quality

  • 2025: Will Congress extend Medicare telehealth coverage?

    2025: Will Congress extend Medicare telehealth coverage?

    Congress will decide whether to extend Medicare Coverage of telehealth services this year. Ruth Reader and Erin Schumaker report for Politico that cost should not be an issue. The latest findings, published in JAMA Internal Medicine, show that Medicare telehealth actually results in lower Medicare spending.

    Congress first expanded Medicare coverage of telehealth services to everyone with Medicare and for a range of services during the COVID pandemic. Until then, Medicare telehealth coverage was largely restricted to people in rural communities. At the end of March of this year, expanded Medicare telehealth coverage will expire unless Congress acts.

    Many policymakers appear to believe that telehealth is driving up Medicare spending and leading to worse health outcomes. But, this new research suggests otherwise. Researchers found that patients received less low-value care or, put differently, higher quality care at lower cost.

    The researchers looked at the records of 2.3 million people with Medicare across 286 health systems. Medicare spending for those patients using telehealth was lower. Patients in health systems using telehealth visited the doctor more but received fewer low-value tests and less unneeded care.

    What were the Medicare savings? The researchers projected at least $66 million. Telehealth visits generally cost less than in-person visits. That said, the Congressional Budget Office projects that two additional years of Medicare coverage of telehealth services will cost about $4 billion.

    Another study published in Health Affairs last year found that people who receive telehealth treatment saw their physicians on an ongoing basis and were more likely to comply with their prescription drug regimens. They also were responsible for fewer emergency room visits.

    Here’s more from Just Care:

  • Poll: Few Americans are happy with health care quality

    Poll: Few Americans are happy with health care quality

    Who could possibly be happy with the quality of care in the United States? Almost no one. A recent Gallup poll should raise alarm bells.

    The cost of health insurance is insane. Insurer restrictions on the physicians and hospitals they will cover is limited and, with deceptive provider directories, misleading. Insurer requirements for preapproval of costly procedures is burdensome. Delays in prior authorization are often harmful to people’s health. And, copays can be exorbitant.

    Findings from a December 6, 2024 Gallup poll underscore the degree of American dissatisfaction with our health care system. Notwithstanding the Affordable Care Act and high levels of insurance coverage, people in the US believe that the quality of care is the worst it has been since 2001, when Gallup first began asking the question.

    1. 89 percent of Americans did not consider US health care to be “excellent.”

    2. One third of Americans (33 percent) consider health care quality “good;” in 2020, 43 percent said it was good.

    3. Nearly four in ten Americans (38 percent) said quality is “only fair.”

    4.  Sixteen percent of Americans consider health care quality to be “poor.”

    5. Only about half of Democrats have a positive view of health care quality. Eight percent fewer Republicans had a positive view.

    6. Americans think less of health care coverage in the US than health care quality. Not even one in three Americans (28 percent) rated health care coverage as “excellent” or “good.” People polled consider  health care coverage worse by four points than in 2001.

    7. As for health care costs, not even two in ten Americans (19 percent) were satisfied. People polled consider health care costs worse by three points than in 2001. Nearly one in four Americans (23 percent) said costs were the top health care problem.  Health care access was the second biggest (14 percent) health care problem.

    Here’s more from Just Care:

  • 2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan

    2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan

    The Annual Medicare Open Enrollment period begins October 15 and ends December 7. If you have Medicare, you are likely to see endless ads and receive lots of mail from an assortment of insurers chomping at the bit to get you to sign up with one of their Medicare Advantage plans. That’s how they rake in the big bucks, tens of billions of dollars a year. Unfortunately, our government does a poor job of helping you to understand differences between traditional Medicare, which is administered by the Centers for Medicare and Medicaid Services (CMS), and Medicare Advantage plans, which are administered by corporate health insurers that contract with the government. And, you can’t trust the corporate health insurers or their sales agents to tell you what you need to know.
    There are five basic differences between Traditional Medicare and Medicare Advantage that you need to understand.
    1. Coverage:
    Traditional Medicare. With traditional Medicare, you are covered for the medicallyreasonable and necessary care your providers believe you need. An insurance company is not second-guessing your doctors.
    Medicare Advantage. Medicare Advantage plans are supposed to cover the same benefits as traditional Medicare, but they cover significantly fewer, as has been documented over and over again. They often engage in widespread inappropriate delays and denials of care and generally require you to get approval before they will pay for most costly services. That’s how they maximize profits. If you think you might get sick or need costly health care at some point, even if you don’t need it now, think twice before signing up with a Medicare Advantage plan. No one provides you with the information you need to know to distinguish the good Medicare Advantage actors from the bad ones. And, there appear to be a lot of bad ones.
    2. Health care providers:
    Traditional Medicare. With traditional Medicare, you can see almost all doctors and use virtually all hospitals anywhere in the United States. Almost all take Medicare and more than 90 percent “take assignment,” accept Medicare’s approved charge as payment in full. The most they can charge is 15 percent above that amount.
    Medicare Advantage. With Medicare Advantage, your care is generally only covered when you use “in-network” providers. They can be few and far between and are often only located in your community. If you travel or spend time away from your primary residence, a Medicare Advantage plan usually will not cover your care, except in emergencies, Also, you might find that the providers in their directories are not taking new patients or have left the network. So, if you are thinking of joining a Medicare Advantage plan or are in one now, talk to any of the doctors you know you want to continue seeing to confirm that you will still be able to have your care covered when you see them. Keep in mind that a lot of the Medicare Advantage plans have lower quality providers in their networks and might not have a cancer center of excellence as part of their network.
    3. Costs:
    Traditional Medicare. With traditional Medicare you must pay your Part B monthly premium. You are generally liable for a hospital deductible and 20 percent of the cost of your medical care, unless you have supplemental coverage, either Medigap, which you buy in the individual market, Medicaid, or retiree coverage from a former employer. If you have supplemental coverage, most if not all of your costs will be covered. Traditional Medicare does not have an out-of-pocket maximum.
    Medicare Advantage. With Medicare Advantage, you pay your Medicare Part B premium and you might have no additional premium, but your out-of-pocket costs can be sky high. You cannot buy supplemental coverage to pick up your out-of-pocket costs. Your costs turn on the Medicare Advantage plan you choose, the care you need, and what the Medicare Advantage plan charges you for your care. You generally will have to pay a copay when you are hospitalized or need medical services. Your out-of-pocket costs can be over $8,000 for in-network care alone if you need costly care. But, each Medicare Advantage plan has its own out-of-pocket maximum. If you go out-of-network for your care, you will be liable for the full cost of your care, unless you are in a PPO (preferred provider organization), in which case you generally will be liable for 40 percent of the cost.
    4. Drugs:
    Traditional Medicare. With traditional Medicare, you will need to buy Medicare Part D prescription drug coverage if you want drug coverage. That typically costs about $55.50 a month.
    Medicare Advantage. With Medicare Advantage, your drug coverage is usually included in your plan’s monthly premium.
    Whether you’re in traditional Medicare or a Medicare Advantage plan, be sure to look at differences in your drug costs among Medicare Part D drug plans. And, keep in mind that it is possible, even likely, that you might spend less getting some of the drugs you take from Costco or another mail-order pharmacy than paying the copay for them through your Part D plan. Part D plans can have higher copays than the total cost of the drug from a low-cost pharmacy.
    5. Quality:
    Traditional Medicare. If you want control over the quality of your health care providers, you probably want to be in Traditional Medicare, where you choose the providers you see.
    Medicare Advantage. In a Medicare Advantage plan, the plan restricts your access to providers. And, even when you see a provider you want to see, the Medicare Advantage plan might not let your physician or hospital provide the care that they think is best for you. For example, if your doctor thinks you need 50 days of inpatient rehab therapy, your Medicare Advantage plan still might decide you only need 10 and will only cover 10 days.

    Bottom line: With traditional Medicare, your doctors and hospitals have every incentive to provide you with all the care they think you need and traditional Medicare will cover it. Medicare Advantage plans receive a fixed amount from the government to cover your care regardless of how much they spend on your care. Consequently, they have an incentive to withhold needed care and to incentivize their physicians to limit the care they provide you. The less money a Medicare Advantage plan spends on your care, the more money the Medicare Advantage plan has for its shareholders. Since there’s no good data to distinguish the good Medicare Advantage actors from the bad ones, you are gambling with your health and well-being when you enroll in a Medicare Advantage plan. To learn more, read this blog post by Diane Archer and Theodore Marmor on the fundamental difference between traditional Medicare and private insurance.

    Here’s more from Just Care:

  • US continues to spend more for poorer quality care than other developed countries

    US continues to spend more for poorer quality care than other developed countries

    Once again, The Commonwealth Fund is out with a report showing that we spend way more than other developed countries for our health care and yet get far less for our money. We spend more per person on health care than every other country and more as a percentage of our gross domestic product. And, unlike every other country, we don’t have guaranteed health care for everyone. 

    We live shorter lives, with average life expectancy of  77 , the lowest life expectancy at birth by three years than other wealthy nations. Black Americans live shorter lives than white Americans, averaging 74.8, as compared to 78.8. And Native Americans still shorter, averaging 71.8. Hispanic Americans have higher life expectancies at birth, 81.9. And Asian American life expectancies are higher still, 85.6.

    Our people have multiple chronic conditions at the highest rate of all nations. We also have higher death rates for conditions that are preventable or can be treated. We have the third highest suicide rates. We have the highest infant and maternal mortality rates. We have 5.4 deaths per 1,000 births and 24 maternal deaths for every 100,000 births. And, we have the highest obesity rates.

    Not surprisingly, more people in the U.S. die from assaults, including gun violence.

    While our government’s focus is on overtreatment, we have far fewer physician visits than people in other countries. We also have proportionately fewer physicians and hospital beds than other developed countries. 

    As a percentage of GDP, we spend about twice as much as the average of other developed countries on health care, at nearly 18 percent. That percentage is growing as prices continue to rise, our population ages, and new technologies for treating patients are developed. 

    On a per person basis, we spend twice as much on total healthcare costs as Germany, the next highest-spending country. And, we spend close to four times as much as most other developed countries.

    Though other developed countries guarantee health care for all, through public health insurance, they generally also offer their residents the right to buy private health insurance. In the US, more than 26 million people—8.6 percent have no insurance at all, and tens of millions more are underinsured, often unable to afford care even though they have insurance. 

    Affordable care for everyone is critical to reining in costs and addressing these terrible quality of care US rankings. Right now, even with insurance, almost half of US residents skipped or delayed getting needed care because of the cost. In addition to reining in health care costs, we must ensure well-coordinated care, including primary care, starting with investing in more primary care providers. 

    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:

  • Data show Medicare Advantage covers less nursing, rehab, home health care

    Data show Medicare Advantage covers less nursing, rehab, home health care

    The Kaiser Family Foundation just released a new study looking at more than 60 past studies of Medicare Advantage. The takeaway is familiar: People with few health care needs fare well in Medicare Advantage. People with costly and complex health care needs receive less post-acute care: they get less nursing, rehab and home health care, often from lower quality providers, in Medicare Advantage. When deciding whether to enroll in Medicare Advantage, keep in mind that health insurance should meet your unforeseeable health care needs down the road.

    The 62 studies, conducted since 2016, focused on people’s experiences affording health care, using health care and getting quality care in traditional Medicare and Medicare Advantage. The authors found that people in Medicare Advantage were less likely than traditional Medicare enrollees not only to use post-acute services but to get treatment in hospitals, skilled nursing facilities, and home health agencies which have the highest quality ratings. The study could not determine whether less use of post-acute care jeopardized health outcomes of study participants.

    We already know from the HHS Office of the Inspector General that Medicare Advantage plans use prior authorization requirements for post-acute services that inappropriately delay and deny care their enrollees need. These “widespread” inappropriate delays and denials likely contribute to why MA enrollees use fewer of these services than people in traditional Medicare, which has no prior authorization requirements for these services. It’s also likely why people with costly conditions tend to disenroll from Medicare Advantage plans at higher rates than other people.

    The data also show that people in Medicare Advantage often forgo care in order to avoid going into medical debt and/or having no money to pay for food and rent. Copays and deductibles can be high in Medicare Advantage plans, particularly for post-acute care. People in traditional Medicare, particularly those with supplemental coverage, experience fewer cost-related problems.

    Medicare Advantage plans do not appear to do a better job of keeping enrollees healthy than traditional Medicare, based on the available data. Satisfaction rates with both care and wait times is similar in traditional Medicare and Medicare Advantage.

    Here’s more from Just Care:

  • Paying more for a Medicare Advantage plan is likely a waste

    Paying more for a Medicare Advantage plan is likely a waste

    If you are choosing a Medicare Advantage plan, keep in mind that you are taking a big gamble: You can’t know whether it will cover the care you need when you need it. The star-rating system is a farce. And, paying more is likely a waste. It’s not a proxy for better quality, according to a new study in JAMA Health Forum.

    The authors find that quality of care in Medicare Advantage does not differ in a meaningful way across premium levels. In fact, they find that there is tremendous variability in quality at each premium level. That said, the authors do report slightly higher quality of care and patient experience in higher-premium plans.

    The takeaway: If you can’t afford the supplemental coverage you need for traditional Medicare and you are choosing among Medicare Advantage plans, you should not choose the Medicare Advantage plan with the higher premium on the theory that it will provide you with better quality care.

    A second takeaway: The additional premium you choose to pay for a Medicare Advantage plan might not bear any relation to significant copays you might face should you need costly care. Those out-of-pocket costs are unknown. Because they can be high, many people end up skipping or delaying needed care in order to avoid paying these costs.

    The bottom line: With Medicare Advantage, what you think is more could very well be less. Higher premiums and “additional benefits” may end up delivering far less than you might think. The problem is that you likely won’t find out the financial and administrative barriers to care you face until it’s too late to disenroll.

    Here’s more from Just Care:

  • Ten ways to improve Medicare Advantage

    Ten ways to improve Medicare Advantage

    Dear Secretary Becerra and Administrator Brooks-LaSure:

    Social Security Works, Just Care USA and Center for Health and Democracy are delighted that the Biden Administration seeks to protect older adults, people with disabilities and the Medicare program from abuses in the Medicare Advantage program. We thank you for the opportunity to comment on ways to improve Medicare Advantage. We agree with the HHS Office of the Inspector General, Government Accountability Office and MedPac that Medicare Advantage is in need of major reform to ensure the health and well-being of enrollees, promote health equity, and minimize legal violations, Including overpayments. As GAO reported: “The Medicare program, which includes MA, is on GAO’s High Risk List, because of its size, complexity, and susceptibility to mismanagement and improper payments.”

    The health insurers offering Medicare Advantage plans have committed many hundreds of legal violations since 2000, and there is reason to believe these will continue unless the federal government overhauls Medicare Advantage. UnitedHealth Group, the company with the most MA enrollees, has paid nearly $600 million in penalties for 332 violations, 300 of which are for consumer protection-related offenses, since 2000. Humana, the second largest MA plan, has paid more than $77 million in penalties for 79 violations, 57 of which are for consumer protection-related offenses, since 2000. CVS Health, the third largest MA plan, has paid more than $1.6 billion in penalties for 463 violations, 236 of which are for consumer protection-related offenses, since 2000. 

    Today, the MA plans have too much incentive and opportunity for abuse. In September 2019, Senator Sherrod Brown, along with five other Senators, wrote CMS requesting answers to questions regarding key failings in Medicare Advantage. To our knowledge, three years later, CMS has not addressed any of the serious issues raised. Unless MA is overhauled on multiple fronts, including revising the way it pays them, Medicare Advantage plans will continue to undermine the integrity of the Medicare Trust Fund, harm health equity, and put millions of their enrollees at serious risk of harm.

    As soon as possible, CMS should stop misdirecting people to believe they can meaningfully choose a Medicare Advantage plan that meets their needs and that they can rely on a misleading star-rating system to choose among MA plans. CMS should:

    • Educate people about the high out-of-pocket costs in MA;
    • Educate people about MA plans’ torturous prior authorization rules;
    • Identify and publicly report the names of MA plans with high rates of delays and denials;
    • Identify and publicly report adjusted mortality rates per MA plan;
    • Terminate contracts with MA plans that are consistently delaying and denying care inappropriately, have high mortality rates, or otherwise are violating their contractual obligations. 

    People from racial and ethnic minority groups, people with disabilities and serious health conditions, people of disadvantaged socioeconomic status, people with limited English proficiency, and people from rural communities disproportionately choose Medicare Advantage because of its low upfront cost. They are, however, at greater risk in Medicare Advantage than in traditional Medicare for two key reasons: 

    Fundamental problems with the current Medicare Advantage model drive health inequities and poor health outcomes for people with complex conditions. The biggest problem is the risk-adjusted capitated payment model. Medicare Advantage plans that: 1. Attract a disproportionate number of enrollees in relatively good health and/or 2. Delay and deny care inappropriately and/or 3. Do not include high quality specialists and specialty hospitals in their networks, can be sure to profit handsomely. The risk-adjusted capitated payment model for MA plans not only hurt vulnerable populations, they drive up Medicare costs. 

    We propose a suite of ten changes to improve health equity, reduce Medicare Advantage threats, enable appropriate CMS oversight, and minimize health insurer violations in Medicare Advantage. 

    1. Change the way the government pays Medicare Advantage plans. 

    The government should pay MA plans so that they do not have a financial disincentive to cover care for people with costly and complex conditions. Prospective payments, unrelated to actual medical claims, create a powerful financial incentive for MA plans to impede access to high-value care for enrollees with complex conditions in order to maximize profits. This is particularly corrosive to health equity:

    • MA plans can maximize profits by enrolling a disproportionate number of people in good health and impeding care for people in poor health. This is one reason why MA plans seldom contract with Centers of Excellence and rarely, if ever, advertise or promote programs for people with costly conditions. 
    • MA plans can maximize profits by underpaying providers. The Texas Hospital Association has identified that “the rapid growth of Medicare Advantage enrollees threatens Texas’ health care safety net. For rural hospitals, Medicare Advantage causes financial instability on an already fragile provider community.” 

    In theory, a risk-adjusted capitated model would pay MA plans enough to cover the cost of services their members need. In reality, however, capitated risk-adjusted models can never ensure access to timely and good quality care for people with costly and complex conditions. In a world in which 50 percent of the Medicare population accounts for less than five percent of spending, such models wildly overpay for the healthy and significantly underpay for the sick.

    Capitated risk-adjusted models create a powerful incentive for Medicare Advantage plans to “cherry pick” the healthy enrollees and “lemon drop” the sick ones. Any Medicare Advantage plan that meets the needs of people with costly conditions — where demand for high-value care is the greatest — is at risk of attracting a disproportionately high percentage of enrollees with costly conditions and suffering financially. Ten percent of people with Medicare with the most serious conditions account for 60 percent of Medicare spending. It makes business sense for MA plans to do what they can to minimize costs from this population. Even good actors must engage in “cherry picking” and “lemon dropping” to ensure they remain financially afloat.

    2. Base payments to MA plans upon the cost of services MA plans cover plus a reasonable fee for administration and a global cap.

    Risk-adjusting capitation payments based upon an MA plan’s own proprietary assessment of the health of its enrollees creates a powerful financial incentive for the plans to “upcode” or attach as many diagnosis codes as possible to its enrollees. The more diagnosis codes, the higher an MA plan’s payments, and the greater the cost to the Medicare program. 

    Upcoding is not simply about bad actors. In order for “good guy” MA plans to compete with “bad guy” MA plans, the good guys are hard-pressed not to engage in upcoding. Otherwise, their competitors have more resources to offer reduced premiums and additional benefits, driving the “good guy” MA plans out of the market. 

    The Department of Justice has identified more than $100 billion of such inappropriate upcoding and overbilling at UnitedHealth Group, Humana, Cigna, Kaiser, Sutter Health and Anthem, among other insurers. It’s anyone’s guess how many additional billions of dollars in overpayments have gone undetected. As a result of upcoding, CMS is projected to overpay Medicare Advantage plans an estimated $600 billion between 2023 and 2031. 

    CMS should acknowledge that it does not have the tools or resources to ensure the diagnosis codes MA plans assign their enrollees are accurate, much less to recoup overpayments. 

    Risk-adjusted capitation adds additional administrative costs and profits to a fee-for-service model. More than 81 percent of MA plans pay all or nearly all their network providers on a fee-for-service basis. Traditional Medicare’s fee-for-service payment model is far more cost-effective and transparent than the MA capitated payment model. Researchers can see what’s working and not working in the health care system, unlike in MA, and drive system improvements. CMS should be building on that payment model.

    3. Require Medicare Advantage plans that pay providers on a fee-for-service basis to use traditional Medicare’s fee schedule. 

    Allowing Medicare Advantage plans to pay lower rates to providers jeopardizes access to care in MA and undermines health equity. Safety net providers serving vulnerable communities, in particular, have little if any leverage to contest MA plan rates and few resources to challenge inappropriate denials of care and coverage, undermining health equity. The Texas Hospital Association has identified that MA plans pay Texas hospitals well below the traditional Medicare rate, which undermines federal payment policies intended to ensure adequate reimbursement for rural hospitals. Medicare Advantage has caused some Texas hospitals to lose several hundred thousand dollars in revenue a year that they had received from traditional Medicare. 

    Conversely, allowing MA plans to pay higher rates than traditional Medicare creates an unlevel playing field with traditional Medicare and drives up Medicare spending needlessly. 

    4. Require MA plans to include all centers of excellence in their networks and disclose out-of-pocket costs for people with complex conditions.  

    The data suggest notable dissatisfaction among MA plan enrollees who need costly care. They disenroll from Medicare Advantage plans at disproportionately high rates in the last year of life and when medical costs are high. A 2021 GAO report suggests that these high disenrollment rates “may indicate potential issues with beneficiary access to care or with the quality of care provided.” In addition, rural enrollees have substantial rates of switching out of Medicare Advantage to traditional Medicare. The data also show widespread and persistent inappropriate delays and denials of care. 

    Until CMS moves away from a risk-adjusted capitated payment model, it must ensure that every MA plan meets the needs of people with the costliest and most complex conditions. Among other things, every MA plan should include all centers of excellence, such as NCI-designated Cancer Centers, in its network. And, rather than allowing MA plans to spend rebate dollars on additional benefits with no evidence of promoting health equity, CMS should consider establishing a mechanism for this money to go towards covering copays and deductibles for people with complex conditions so as to help ensure they are not forced to choose between their rent and their health care.  

    5. Standardize MA coverage rules and cost-sharing design.

    Even the most diligent people with Medicare have no way to select the MA plan that best meets their needs. Each Medicare Advantage plan structures its out-of-pocket costs and out-of-pocket limits in different ways, uses different medical necessity protocols, different referral and prior authorization requirements, designs different networks, and engages in different levels of inappropriate denials of care and coverage. Consequently, some Medicare Advantage plans could literally be harming their enrollees while others could be ensuring timely access to care and delivering good health outcomes. No one can meaningfully differentiate among these plans.

    These structural differences among MA plans, several of which can change at any time, could be disabling or even killing people with Medicare prematurely – and CMS itself would not know. These differences prevent CMS from both protecting enrollees and evaluating MA plans in a meaningful way. At the same time, they prevent people with Medicare from being able to compare MA plans on the most essential metrics. 

    Structural differences also make it all but impossible for CMS to undertake timely and effective audits of MA plans. CMS has not been able to complete timely MA audits from as far back as 2011. Without such audits, CMS cannot protect enrollees in MA plans or hold MA plans appropriately accountable for their bad acts in a timely fashion. CMS should acknowledge that it will never have the tools or resources to appropriately penalize MA plans for bad acts and protect MA enrollees without standardized MA design. 

    People with Medicare today are inadequately protected against proprietary and non-standardized MA policies that could jeopardize their health and well-being. The data show that CMS cannot effectively monitor them for poor outcomes. A 2022 OIG report, a 2018 OIG report, and endless news stories consistently show that Medicare Advantage plans too often inappropriately deny care that traditional Medicare would have covered and that the MA plans should have covered. CMS should require all MA plans to follow traditional Medicare coverage protocols and only allow evidence-based and transparent differences among MA plan protocols. 

    6. Ensure appropriate oversight of MA.

    CMS does not have the tools or resources to ensure appropriate Medicare Advantage oversight and protect enrollees under the current non-standardized model. Standardizing coverage policies would allow CMS to monitor MA plans more effectively and better protect enrollees. Standardized coverage protocols would help ensure MA plans covered medically necessary care and promoted health equity. 

    The GAO has found that CMS has not validated MA patient encounter data as needed and recommended. In a recent House Ways and Means Subcommittee on Oversight and Investigations hearing, MedPAC reported that “After a decade, MA plans are “not producing complete and accurate enough records needed for MedPAC to conduct oversight activities, to understand differences in service use between MA and FFS, to reflect utilization management techniques, and inappropriate denial of covered care.” 

    The failure of Medicare Advantage plans to turn over complete and accurate encounter data for analysis — as required by law — suggests these plans either lack the tools to collect the data or the ability to appropriately manage their enrollees’ care.

    7. Do not assume value in MA, since it cannot be measured. 

    MedPAC has said repeatedly that MA quality cannot be measured. “The current state of quality reporting in MA is such that the Commission can no longer provide an accurate description of the quality of care in MA. With 43 percent of eligible Medicare beneficiaries enrolled in MA plans, good information on the quality of care MA enrollees receive and how that quality compares with quality in FFS Medicare is necessary for proper evaluation. The ability to compare MA and FFS quality and to compare quality among MA plans is also important for beneficiaries. Recognizing that the current quality program is not achieving its intended purposes and is costly to Medicare, in its June 2020 report the Commission recommended a new value incentive program for MA that would replace the current quality bonus program.” Medicare Advantage plans’ higher per enrollee costs than traditional Medicare suggest Medicare Advantage offers less value than traditional Medicare. 

    We know that MA plans spend less money on medical care than traditional Medicare. But, we do not know to what extent they are failing to cover appropriate medically necessary care that traditional Medicare covers. Moreover, industry data on 2018 hospital stays and emergency room visits reveal that Medicare Advantage appears to have greater inpatient use and emergency room visits than traditional Medicare. In a review of the Medicare Advantage studies, Agarwal and colleagues find “the evidence on readmission rates, mortality, experience of care, and racial/ethnic disparities did not show a trend of better performance in MA plans than traditional Medicare, despite the higher payments to MA plans.”

    Assessing MA plan quality is critical for the health and well-being of MA enrollees. Given the poor performance of some MA plans with four and five-star ratings and no information from CMS on bad actors with these ratings, people are at risk of worsened health outcomes if they choose the wrong MA plan. One MA analysis in NBER found that if CMS cancelled contracts with the worst performing five percent of MA plans, it would save 10,000 lives a year.

    To protect people from misleading quality information, CMS should revise its star-rating system, as proposed by MedPAC. It should also eliminate star ratings for all Medicare Advantage plans that do not release complete and accurate encounter data, as required. And, it should consider removing these MA plans from eligibility for the quality bonus program. 

    8. Rethink Medicare Advantage networks. 

    CMS should stop allowing Medicare Advantage plans, except those that are fully integrated health systems, to design their own provider networks and require them to cover care from all Medicare providers. Many if not most MA plans design their networks to minimize their costs and boost their profits to the detriment of the health and well-being of their enrollees. To our knowledge, no independent expert has ever demonstrated the value of a network in Medicare Advantage plans to people with Medicare or the Medicare program other than those in fully integrated health systems. Conversely, stories abound about Medicare Advantage narrow networks that jeopardize access to care and lead to poor health outcomes, particularly for vulnerable populations.

    If the principal reason for a provider network is to contain medical costs, there is no compelling justification for Medicare Advantage plan networks. MA plans generally piggyback off of Medicare rates, which are already relatively low. If MA plans negotiate even lower rates, there’s good cause for concern that providers in their networks are of lesser quality than in traditional Medicare. If the principal reason for a provider network is to ensure good integrated care, it is difficult to appreciate the value of MA provider networks (except in cases where the Medicare Advantage plan is a fully integrated health care system). 

    The risks to the health and well-being of MA enrollees of allowing MA plans to design their provider networks are grave. Compared to traditional Medicare, the data show that MA plans use lower quality home health agencies and nursing homes, and less frequently use higher quality hospitals. They often do not include NCI-designated Cancer Centers or Centers of Excellence. In 2016, the Kaiser Family Foundation found that only 15 percent of Medicare Advantage plans definitely included Cancer Centers and 41 percent definitely did not.

    Plan networks are often so narrow as to delay or prevent people from accessing needed care. They also often undermine continuity of care. And, many MA plans have never had accurate network directories. Plan provider directories are too often misleading and inaccurate. Without accurate directories, network adequacy cannot be established. 

    Moreover, GAO reports that CMS does not assess provider availability to the extent it oversees network adequacy. This failure undermines health equity. Vulnerable older adults and people with disabilities are more likely to go without care when networks are narrow and accessing care with network providers requires significant time and travel.

    We urge CMS to acknowledge that it has neither the tools nor the resources to ensure network adequacy and promote health equity. A 2015 GAO report found “that CMS’s oversight did not ensure that MAO networks were adequate to meet the care needs of MA enrollees. For example, we found that CMS did not adequately verify the accuracy of provider network information submitted by MAOs, and accordingly could not verify whether MAO networks were in compliance with the agency’s provider network criteria.” In June 2022, GAO stated that its recommendations to address these issues “had not yet been fully implemented.”

    To promote health equity, protect people from misleading MA marketing regarding network providers, and ensure access to and continuity of care, CMS should consider requiring MA plans, except fully integrated health systems, to cover care from all Medicare providers. At a minimum, CMS should require those plans that do not keep their directories up to date to open their networks to all Medicare providers. 

    9. Rethink key consumer information regarding Medicare Advantage and overhaul MA marketing to minimize deception. 

    CMS should ensure that people enrolling in a Medicare Advantage plan are able to identify which of those plans are the bad actors, if not cancel contracts with these bad actors. Allowing these bad actors to continue offering MA plans endangers the health of the most vulnerable people with Medicare and undermines health equity.

    CMS also should ensure that no one enrolls in Medicare Advantage without understanding the financial and administrative barriers to care. A recent Center for Medicare Advocacy report found that even the “Medicare and You Handbook” and Medicare website do not explain out-of-pocket costs or prior authorization requirements in a balanced fashion. 

    CMS reported a doubling of MA marketing complaints in the year between 2020 and 2021. Too often people with Medicare have little clue what they are doing when they enroll in a Medicare Advantage plan. CMS’ review of sales calls showed significant confusion among people with Medicare, including “that the beneficiary may be unaware that they are enrolling into a new plan during these phone conversations.”  Of those people who understand differences between traditional Medicare and MA, few appreciate the risks of enrolling in a Medicare Advantage plan.

    10. Level the playing field with traditional Medicare and ensure health equity in MA.

    We urge the government to put an out-of-pocket cap in traditional Medicare so that traditional Medicare is a meaningful choice for everyone with Medicare, including people with low incomes, people in rural communities, people from racial and ethnic minority groups, and people with complex conditions. Without that out-of-pocket cap, the hundreds of thousands of people who face inappropriate delays and denials of care in Medicare Advantage too often are deprived a meaningful choice of traditional Medicare. If they elect traditional Medicare, they expose themselves to too much financial risk because supplemental insurance is unavailable or affordable for them. 

    CMS should consider allowing people in MA to have supplemental coverage that picks up all out-of-pocket costs. Right now, too many enrollees, particularly the most vulnerable, are skipping or delaying critical care because they cannot afford the deductibles and copays, creating substantial health inequities. One NBER study found that a copay increase of as little as $10.40 resulted in thousands of needless deaths. Supplemental coverage would allow people to better budget for their care. Out-of-pocket costs jeopardize the health and well-being of enrollees, with particularly poor outcomes for Latinx and BIPOC communities. In addition, out-of-pocket costs present a large barrier to care for people with low incomes.

    Conclusion

    Medicare Advantage would be significantly improved by:

    • overhauling the Medicare Advantage payment system,
    • meaningfully disclosing MA encounter and other data,
    • holding accountable those MA plans that violate their contracts, 
    • standardizing coverage policies and provider rates, including prior authorization policies, 
    • requiring a broad Medicare provider network, and 
    • overhauling Medicare Advantage marketing practices. 

    Without these reforms, the federal government puts the lives of the most vulnerable people with Medicare enrolled in MA at serious risk and threatens the integrity of the Medicare Trust Fund. It wrongly drives up Medicare Part B premiums for people in traditional Medicare. 

    Traditional Medicare would benefit from some improvements as well, including an out-of-pocket cap on Part A and B benefits and coverage of dental, hearing, vision and long-term care benefits. CMS also needs to end its Direct Contracting/ACO REACH experiment, which involuntarily assigns vulnerable people with Medicare to entities paid upfront to manage their care and is riddled with many of the same grave problems as Medicare Advantage. That said, traditional Medicare generally still provides easy access to necessary care at substantially lower cost than Medicare Advantage, and CMS should ensure that it is a meaningful choice not only for the wealthiest people with Medicare but for everyone with Medicare. 

    We look forward to working with CMS on Medicare improvements. Thank you for this opportunity to share our thoughts. For questions, please contact Diane Archer at [email protected]. 

    Signed,

    Diane Archer, President, Just Care USA

    Alex Lawson, Executive Director, Social Security Works

    Wendell Potter, President, Center for Health and Democracy

  • Medicare seeks to stop disclosing hospital safety information

    Medicare seeks to stop disclosing hospital safety information

    It’s bad enough that hospitals can be dangerous places, yet most people check in to a hospital without knowing whether the hospital is safe for patients. For years now, Medicare has published some data on hospital safety and rated hospitals from one to five stars based on those ratings. Rachel Cohrs reports for Stat News that Medicare might stop doing so, although that information can help people avoid being admitted to an unsafe hospital.

    Hospital-acquired infections can literally kill patients, and each year thousands of people die from them. One in four people with Medicare are harmed in the hospital. They get sepsis, a life-threatening infection, or some other serious illness while being treated for something else in hospital.

    So, while Hospital Compare, Medicare’s online hospital quality comparison tool, is far from perfect, it’s worth checking out.  Medicare also has tools for comparing nursing homes and other health care providers. But, the government agency that compiles the care compare data lost a bunch of funding and is looking to cut back on the data it provides the public.

    Medicare wants to hide from public view 10 measures it has disclosed to promote patient safety and warn patients of poor quality. It wants to keep secret information on rates of hip fractures, sepsis post surgery and pressure ulcers in hospital. According to the Leapfrog Group, each year nearly 25,000 patients die from these hospital-acquired illnesses.

    Of course, the hospitals love the idea that Medicare would stop publishing this data. They argue that it is imperfect because it cannot capture the condition of patients before they are admitted, which could make them more prone to harm in hospital. While that is true, it’s true for all patients at all hospitals.

    As you would expect, patient advocates strongly oppose it because it exposes patients to a lot of risk. Without public data, it’s hard to drive health care facilities to improve the quality of care they provide their patients.

    What’s super concerning is that Covid-19 has hurt patient safety in hospital significantly. In the first six months of 2021, US rates of central-line associated bloodstream infections in hospital were up 45 percent after having come down 31 percent in the five years before the Covid-19 pandemic. MRSA infection rates were up 39 percent. Yet, informing the public about patient safety appears to be low on the Biden administration’s agenda.

    To be clear, pre-pandemic, some hospitals performed extremely poorly from a quality perspective. The HHS Office of the Inspector General (OIG) found that, in 2018, 25 percent of Medicare patients who were hospitalized suffered from some time of harm while in hospital. In 2010, a similar OIG analysis found the same rate of harm to Medicare patients.

    As proposed, Medicare would still collect quality data. But, it would not impose fines on hospitals that performed poorly on the quality measures.

    Here’s more from Just Care:

  • Most Medicare Advantage plans will see lower star-ratings

    Most Medicare Advantage plans will see lower star-ratings

    Robert King writes for Fierce Healthcare about a change to Medicare’s star-rating system for Medicare Advantage plans. As a result of Medicare’s change to its star-rating system, a new analysis finds that the overwhelming majority of Medicare Advantage plans will face lower star-ratings.

    For some time now, the federal government has tried–unsuccessfully–to help people distinguish among Medicare Advantage plans–corporate health insurance plans that are paid to cover Medicare benefits. Medicare Advantage plans are an alternative to traditional Medicare, which is public health insurance that covers your care from most doctors and hospitals across the US and is administered directly by the federal government.

    The government uses a “star-rating” system to help people distinguish among Medicare Advantage plans. But, the stars the government gives Medicare Advantage plans are no way to gauge whether a Medicare Advantage plan will cover your care from physicians you trust when you need it.  From the perspective of people with Medicare, the stars are a farce because the Medicare Advantage plans have been able to game them and they do not measure key differentials among Medicare Advantage plans. For example, the star-rating system does not factor mortality rates in different Medicare Advantage plans and rates of inappropriate delays and denials of care.

    The Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare, is now raising the bar for getting stars in 2023.  It will be giving double the weight it has to customer service, accessing prescription drugs, care coordination and health care quality.

    Under this new way of calculating star-ratings, nearly 50 percent of Medicare Advantage plans would lose one star. The loss of a star speaks to the difficulty that enrollees are increasingly facing getting prescription drugs in their Medicare Advantage plans. More Medicare Advantage enrollees are unsatisfied with their ability to fill their prescriptions at a reasonable out-of-pocket cost.

    From the Medicare Advantage plans’ perspective, losing a star or two means loss of significant revenues, often millions and sometimes billions of dollars. Without that money, Medicare Advantage plans might not be willing to offer as generous benefits. It will also be harder for them to retain enrollees.

    More than four in ten (44 percent) Medicare Advantage plans could lose a star because their enrollees are less satisfied with customer service and care coordination.

    Press Ganey performed the analysis in early 2022, based on data from 446 Medicare Advantage plans.

    Since 2015, Medicare Advantage plan quality bonuses have nearly quadrupled, from $3 billion to $11.6 billion. Part of the increase is attributable to the government awarding bonuses to more Medicare Advantage plans. Part of the increase is attributable to the number of enrollees in the Medicare Advantage plans that received bonuses.

    Here’s more from Just Care