Medicare Advantage enables eligible beneficiaries to access Medicare benefits through a private sector health insurer. It’s seen consistent growth in the past decade and should surpass traditional Medicare as the most-used Medicare solution.
As with any program with government oversight of private sector participants, it’s constantly evolving, weighing consumer needs with health plan capabilities. CMS recently published CMS-4203-NC seeking feedback on the future of the Medicare Advantage plans.
The Alliance of Community Health Plans (ACHP) submitted a response in late August of 2022. The alliance is uniquely qualified to shape the future of Medicare Advantage plans because its members are top-performing nonprofit, provider-aligned health plans. Those plans provide coverage and care to 23 million Americans.
ACHP’s response focused on four key areas, health equity and social determinants of health, expanding access, person-centered care, and affordability and sustainability. Below is a summarization of ACHP’s feedback and their potential impact on the future of Medicare Advantage plans:
Health Equity and the Social Determinants of Health
Research has shown that many factors impact health outcomes. Genetics, social and environmental factors, and behaviors may play more of a role in health outcomes than actual health care. As a result, government programs and health insurers are investing more in the social determinants of health (SDOH) to achieve health equity.
Addressing SDOH begins with data collection. The ACHP proposes a framework that includes recommended questions for collecting that data and the flexibility that enables health plans to deliver more personalized engagement.
Among other recommendations, ACHP would like more SDOH data sharing within other government programs and agencies. Such sharing would help bridge data gaps that can impact care. Additionally, the organization would like guidance from the Centers for Medicare and Medicaid Services (CMS) on data governance so health plans can create guidelines when they discover conflicting information.
As ACHP points out, successful SDOH strategies start with community partnerships that help members meet social needs. That may include faith groups, barber shops, and community centers. Partnering with these small organizations may be difficult due to regulations – like HIPAA – that are burdensome or overly expensive for small community organizations.
Though ACHP members successfully created targeted food security interventions, the organization notes that the enrollment process is “complex, long, and duplicative.” Not only should that process be streamlined, but all government agencies need to activate to understand disparities and enable ACHP to deploy solutions.
What’s the Future of Medicare Advantage Plans Look Like?
Health plans will increasingly look to SDOH to improve health outcomes. But to address SDOH, more and better data is required and needs to be shared among all participants so targeted strategies can be deployed. But there also needs to be more streamlined, less costly, frameworks that make it easier to partner with local resources that can impact SDOH.
The COVID-19 pandemic accelerated the use of telehealth. But as COVID becomes endemic and emergency authorizations expire, Medicare Advantage plans will require additional support from CMS and Congress. ACHP will continue to push for Congress to make emergency authorizations permanent. Additionally, ACHP requests that the administration create guidelines that promote virtual value-based care.
The organization would also like to expand telehealth credits for certain providers to meet network adequacy requirements. Those requirements are hard to meet in rural areas where providers – especially specialty providers – won’t expand due to limited patients. Contracting with these specialty providers can deliver better access in rural areas.
Like incentives that encourage telehealth, ACHP pressed for incentives for behavioral health organizations to contract with health plans. Because many behavioral health providers don’t accept insurance – and there’s no incentive to do so – consumers must pay out-of-pocket, which impacts their ability to receive treatment.
Additionally, ACHP suggests CMS reimburse providers like licensed mental health counselors, licensed professional counselors, and marriage and family therapists. Reimbursing these alternative providers will improve patients’ access to care amidst a workforce shortage.
Enrolling in a Medicare Advantage can be confusing for most beneficiaries. Many Medicare beneficiaries assume Medicare, Medigap, and Medicare Advantage are the same. Educating members takes time and effort. As a result, ACHP recommends CMS create a technical expert panel with consumers and consumer groups to develop information about Medicare options. ACHP also recommended CMS focus on Star Ratings so that consumers understand how quality is measured in the Medicare Advantage market.
Though CMS recently released more guidance related to Medicare Advantage marketing by third-party marketing organizations (TPMOs), the ACHP feels TPMOs not only use misleading tactics but also often steer members to national plans instead of regional ones.
ACHP also called out the “questionable practices” of private equity when steering consumers to health plans that ultimately help the private equity firm. What’s the solution? ACHP suggests regulating those private equity firms.
What’s The Future Look Like?
Telehealth will become ubiquitous; it will allow for access to better providers, especially in rural areas that providers won’t invest in. CMS could expand behavioral health services. Better enrollment education and resources that help the beneficiary make a more informed choice could be part of the Medicare Advantage of the future.
Recent price transparency regulations have made it easier for consumers to view the true price of healthcare. But the ACHP suggests those transparency regulations lack the context that might undermine the intent of the rules. Because quality measures aren’t included, the fear is that consumers will think higher prices mean higher quality care. Plus, the files health plans are required to generate are difficult to understand. They are also so large that even third parties spend a lot of time translating them into consumer-friendly results. As a result, those transparency measures aren’t meeting the needs of consumers.
ACHP also envisions CMS including incentives for both payers and providers to encourage better outcomes, like updated provider directories and advanced EOBs. Collaboration between providers and payers is the key to the successful implementation of those policies.
Person-centered care – like the care that addresses SDOH – requires robust, person-level data. Interoperability regulations can help but do add a regulatory burden that strains the resources of some regional health plans. ACHP requests that CMS create a set of standards to collect race and ethnicity data, specifically.
But incentives are also necessary for both payers and providers. Without provider incentives, payer data will be incomplete because providers have more regular consumer interactions.
ACHP members are strong supporters of value-based care. But they need the administration’s help expressing the positive results of value-based care relationships for the model to take hold industry-wide.
Medicare Advantage Star Ratings help consumers compare the quality of plans. However, according to ACHP, efforts could be made to improve Star Ratings for consumers. Specifically, the organization felt CMS should consistently review and update the Star Ratings program. They found the program has too many measures, overly weighs process measures, doesn’t focus singularly on patient experience and outcomes, and rewards consistency more than improvement.
Additionally, the measurements that drive ratings could be digital, use new data sources, and leverage more advanced measures to improve experience evaluations.
What’s the Future Look Like?
Pricing transparency data that are accessible and usable for the consumer. Better collaboration between payers and providers to get pricing information to the consumer. Star Ratings that focus more on patient experience, patient outcomes, and plan improvements could be the norm. CMS could implement process improvements that increase the depth of information considered in Star Ratings while making it easier to gather that data. Finally, there will be a continued march toward value-based arrangements.
Affordability and Sustainability
In the entire document, the only suggestion that ACHP bolded is this: “ACHP has repeatedly called for the transition to encounter data and elimination of the across-the-board coding intensity adjustment which unfairly creates winners and losers based on coding practices.” Modernization of risk adjustment – including the incorporation of SDOH – appears to be a primary recommendation by ACHP.
ACHP reacted to overly burdensome regulations when suggesting improvements to affordability and sustainability. The organization believes that CMS can streamline quality measurement, audits, and network adequacy reviews by using artificial intelligence and machine learning. Integrating those technologies would enable near real-time reviews of submitted data. ACHP also thinks CMS can leverage its data to identify providers to avoid.
Finally, ACHP supports electronic and automated prior authorization but would like it consistently applied across programs. Doing so would ensure health plans don’t need to follow different rules across different products. It also supports a phased-in approach so health plans have time to implement the changes necessary for success.
What’s the Future Look Like?
CMS could eliminate coding intensity adjustments. The agency could also streamline burdensome regulatory requirements with AI and ML. Health plans could digitize and automate prior authorization processes.
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