What Shall We Do About Medicare Advantage?
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CMS has published the final 2024 Medicare Advantage (MA) rule (here) which addresses prior authorization tools which MA health plan sponsors use to require physicians and other clinicians to obtain insurer approval before offering a service or drug from whatever checklist the MA sponsor is following.
A CMS “fact sheet” (here) says that the final rule also addresses “changes related to Star Ratings, marketing and communications, health equity, provider directories, coverage criteria, prior authorization, network adequacy, and other programmatic areas.”
In general, CMS is attempting to provide guard rails for MA plans, to ensure that enrollees in those plans have the same access to services as would be found in “traditional” Medicare. “The final rule also streamlines prior authorization requirements, including adding continuity of care requirements and reducing disruptions for beneficiaries. CMS’ final rule requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary.”
The CMS fact sheet notes “Second, this final rule requires coordinated care plans to provide a minimum 90-day transition period when an enrollee currently undergoing treatment switches to a new MA plan, during which the new MA plan may not require prior authorization for the active course of treatment. Third, to ensure prior authorization is being used appropriately, CMS is requiring all MA plans establish a Utilization Management Committee to review policies annually and ensure consistency with Traditional Medicare’s national and local coverage decisions and guidelines.”
“Finally, to address concerns that the proposed rule did not sufficiently define the expected duration of ‘course of treatment,’ the final rule requires that approval of a prior authorization request for a course of treatment must be valid for as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.”
To guard against MA plan predatory marketing, the final rule notes that “The proliferation of certain television advertisements generically promoting enrollment in MA plans has been a specific topic of concern. To address these concerns, CMS is prohibiting ads that do not mention a specific plan name as well as ads that use words and imagery that may confuse beneficiaries or use language or Medicare logos in a way that is misleading, confusing, or misrepresents the plan.”
The Longer Term—MA Plans and Sick Enrollees
The lead article in this week’s New England Journal of Medicine (here) addresses a longer term problem, namely, with the growth of MA plans, the plans’ enrolled populations will normalize. Marketing strategies to attract younger seniors (with lower health costs) will no longer guarantee a lower cost population. The monetary gain to MA plans from their “risk adjustment” efforts--gathering information about comorbidities and indicia of ill health which may or may not have been present, in order for the MA plan to receive higher reimbursement--may pale in comparison to the financial changes for MA plans if patients who actually are riskier (not only “risk adjusted”) are enrolled.
What happens, in other words, if MA plans have sick enrollees who need sophisticated and expensive medical care?
The nine high powered authors of the NEJM piece, including Harvard’s David Grabowski, a former MedPAC Commissioner, note candidly that “For enrollees with serious illness, who often require extensive care provided in multiple settings, the [MA] program’s cost-control mechanisms — such as coverage denials, narrow provider networks, and prior-authorization requirements — may undermine the ability to receive necessary or high-quality care.”
With regard to “extras” advertised by MA plans, the “supplemental benefits that can address needs that are traditionally seen as nonmedical, including meal, transportation, and caregiver-support benefits . . . information on the frequency with which plans offer these benefits, who they are offered to, how they are delivered, and their effects on quality of care and beneficiary experience isn’t available.”
On the Quality Bonus Program (QBP), “A decade after the QBP’s implementation in 2012, however, concerns about its accuracy in measuring quality and its ability to drive quality improvement have been persistently documented in academic research and MedPAC reports,” and “Despite CMS’s substantial investment in the QBP, there is no evidence that the program has improved the quality of care in Medicare Advantage.”
The authors conclude, “With the program projected to enroll up to 60% of Medicare beneficiaries by 2030, urgent reevaluation is needed . . . aimed at reforming Medicare Advantage to better meet the needs of people with serious illness.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Credibility of Information on Physician “Rating” Websites
Research in Health Policy (here) addresses “the credibility of online reviews [which] is drawing critical attention due to the lack of control mechanisms, the constant debate about fake reviews and, last but not least, current developments in the field of artificial intelligence. For this reason, the aim of this study was to examine the extent to which assessments recorded on physician rating websites (PRWs) are credible, based on a comparison to other evaluation criteria.”
Results: “This study has shown that ratings on PRWs seem to be credible when relying primarily on patients’ perception. However, these portals seem inadequate to represent alternative comparative values such as the medical quality of physicians. For health policy makers our results show that decisions based on patients’ perceptions may be well supported by data from PRWs. For all other decisions, however, PRWs do not seem to contain sufficiently useful data.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH FACILITIES
Leadership, Minnesota Style
A report in the Minnesota Reformer (here) says that “Mayo Clinic has given Gov. Tim Walz and state lawmakers an ultimatum over two bills that aim to increase nurse staffing levels and rein in health care costs: Gut the bills or the nonprofit hospital will pull billions in planned investments out of the state.”
“Mayo Clinic, the state’s largest private employer with over 48,000 workers, has been spearheading a decade-long redevelopment effort in Rochester to turn the small southern Minnesota city into the ‘Silicon Valley of medicine,’ helped by hundreds of millions in public money. In 2013, the Mayo Clinic also made a last-minute threat that it would bring billions in investments for Destination Medical Center to another state if lawmakers didn’t contribute $500 million toward the project.”
EHRs and Dx Error = Legal Claims
A study in JAMA Network Open (here) analyzed closed legal claims linking electronic medical record systems and diagnostic error. “We sought to identify whether problems with EHRs are associated with diagnostic errors, in which part of the diagnostic process errors occur, and the specific types of errors that occur.” One result was that “Of the 199 diagnosis-related claims, the EHR was considered a potential contributor to the diagnostic error in 122 claims (61.3%)” and “Of the 122 claims with EHR as a potential contributor, 91 (74.6%) claims had a judgment or settlement noted.”
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Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org
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