The Case For Greater Focus On Innovation In Medicare Advantage

The Center for Medicare & Medicaid Innovation (Innovation Center) is licensed under Section 3021 of the Affordable Care Act. Its purpose is to give the Centers for Medicare & Medicare Services (CMS) Innovation Center a renewed $10 billion congressional budget allocation every 10 years to test new models and the authority to scale successful pilots. was to streamline the implementation of new payment and delivery models. When the Innovation Center was established in 2010, it was expected to accelerate an era of payment services reform in the United States.

Since then, the Innovation Center’s track record has been mixed at best. Centers can extend their mathematically certified models as they improve quality and reduce costs, but only a handful of them are certified. Importantly, the scope of the portfolio has been narrowed, initially focusing on models that improve the coordination of care in the Fee for Service (FFS) Medicare program. About 50% of Medicare beneficiaries currently participate in the Medicare Advantage (MA) program and have been underrepresented in the government’s innovation portfolio. The only notable exception is the MA value-based insurance design (VBID) model.

The reasons for this underestimation can be manifold.

First, when the center was founded (when I was part of the founding team), MA was not as prominent as it is today, with only 25% of beneficiaries seeking Medicare benefits from private health insurance in 2010. did. , MA programs have skyrocketed in popularity as more Medicare beneficiaries opt for MA’s richer benefits and more predictable costs.

Second, there has long been an undeniable prejudice against MA, formerly known as Part C: Medicare+Choice. In its first implementation in the late 1990s, the program was plagued with fraud, waste and abuse, as well as questionable marketing and benefits design practices. As a result, federal policy analysts and political officials who set the Innovation Center’s agenda saw it as a marginal program inferior to FFS Medicare.

However, with the current growth of MA programs and growing political attention to their shortcomings, innovation centers should pay more attention to MA innovations that improve the quality of care and reduce costs. Given the huge popularity of MA programs in poor, marginalized minority communities, the MA-focused innovation center agenda is well suited to the Biden administration’s expressed interest in promoting health equity. is consistent with

The enhanced Innovation Center’s focus on MA can focus on new solutions to address the set of challenges identified in the programme.

One set of models could focus on introducing new ways to identify and reward risk that leverage data and real-time arbitrage. CMS now reimburses MA plans that serve sick patients through a hierarchical condition category (HCC) coding system. Appropriate risk adjustment systems are necessary to ensure that health plans seek out and serve the sickest patients. However, the system is “gamed”, overpaying some patients and underpaying others. Innovation Centers can experiment with new ways to assess risk and reward, powered by real-time adjudication and machine learning. These new approaches will help reduce fraud, waste, and abuse and make the Medicare program more sustainable.

A second set of models could focus on new methods of quality measurement and modernization of star rating programs. The Star Rating Program now provides reputational and financial rewards to health plans that deliver higher levels of service and clinical quality to health plan members. However, the Star Rating program focuses on individualized sets of preventive measures and health insurance experience scores, and could do more to focus on true quality of care and health equity. I can. One emerging area of ​​concern for MA plan beneficiaries is the use of proactive usage management practices. The Innovation Center is testing a new star rating program that introduces a series of “Medicare Advantage Never Events” to ensure that health plans can deliver on their promise to coordinate care and not cut corners to meet financial goals. We can make it possible. We can also test new “improvement factors” that reward MA plans to reduce disparities among underserved populations.

A third set of models can focus on special populations currently underserved by the Medicare program. While CMS offers Special Needs Plans (SNPs), there is also an opportunity to enhance SNP’s existing portfolio and test additional plans. For example, CMS has a dementia SNP whose design limits enrollment and popularity, but demographic headwinds warrant more attention to this population. In addition, health plans that focus on addressing the growing needs of older people experiencing homelessness and those with disabilities may also benefit. Older adults will greatly benefit from the creation of a new MA health plan model specifically targeted at populations underserved by FFS Medicare and the existing array of MA services.

A fourth set of models could focus on new sales and distribution models leveraging MA brokers to promote more health care and medical prevention. There has been increased scrutiny of deceptive marketing practices by MA brokers, most recently an investigation by the Senate Finance Committee headed by Chairman Ron Wyden (OR) and an investigation by US Representatives Mark Pokan (WI-02) and Law・There was a call from Kanna (CA-17). Prohibits insurance companies from using “Medicare” in advertising. Massachusetts brokers receive an upfront commission and annual “tail payments” for life for each beneficiary who enrolls in the plan. The best brokers earn this tail payment by providing ongoing care coordination and navigation to their beneficiaries. and may have opportunities to strengthen their role as health advocates on behalf of the beneficiaries they serve, while improving the quality of care and services in the process.

Unfortunately, the federal debate over MA has devolved into an oversimplified academic debate about whether the outcomes and costs are better or worse between MA and FFS Medicare. This debate continues to unfold, and importantly, people talkedAs of January 1, 2023, more than half of Medicare beneficiaries choose to receive Medicare coverage through a privately administered MA plan rather than through FFS Medicare. The need for innovation in programs has never been more urgent or relevant.

CMS and Innovation Center all Rapidly accelerate work to improve management of MA programs.