The Alliance of Community Health Plans on Monday (June 12) called for a major revamp of Medicare Advantage to strengthen its guardrails, calling for CMS and Congress to overhaul quality measures and bonuses, restructure marketing parameters and broker compensation, and realign the risk adjustment system.
“In the case of MA, the star ratings system for quality resembles the ‘everyone gets a trophy’ environment of Lake Wobegon,” ACHP says in a fact sheet on the proposed policies. “The most aggressive risk-adjusters have discovered it is easier to code their way to revenue than achieve it through quality. And consumers are inundated with aggressive marketing and enrollment strategies complicating an already complex process. For too long, the fight in Washington has been over MA payment rates, rather than better health for people 65 and older.”
Medicare Advantage enrollment surpassed traditional Medicare earlier this year, and that growth has been accompanied by efforts to enhance the program’s guardrails and upgrade aspects of MA that some argue aren’t serving beneficiaries or making good use of federal dollars.
ACHP’s new plan, MA for Tomorrow, breaks those policies into five areas: improving quality, streamlining consumer navigation, restructuring risk adjustment, modernizing network composition and realigning benchmarks. ACHP released details on the first three policies, but details on the final two pillars aren’t expected until later this summer.
ACHP is seeking to accomplish a number of its proposed changes through rulemaking, and CMS has expressed interest in the recommendations, Michael Bagel, associate vice president of public policy, told IHP. But ACHP is also planning to seek congressional support on the policies, Bagel added.
ACHP’s top priority is revising the quality system to focus more on patient experience and outcomes measures, rather than the current process measures, which ACHP says are easy standards for plans to meet but aren’t always indicative of a plan’s quality.
The new system should also limit how many MA contracts can achieve each overall star rating – including the highest five star rating – which could help improve the ratings’ accuracy. Nearly three in four plans currently boast a four- or five-star rating, which dilutes the significance of the rating and makes it challenging for beneficiaries to assess whether a plan is high-quality or not, ACHP says.
Measure collection should also be revised to help capture patient experience and outcomes, which Bagel told IHP could be accomplished by utilizing technology and improving the consistency of that data collection.
ACHP outlined 10 process measures CMS should consider eliminating, such as the price accuracy quality measure, Bagel noted. Those measures are either poorly designed or have clustered rates of achievement at the top of the scale, ACHP says on its website.
ACHP also wants to improve the practices surrounding MA marketing by standardizing broker payments and creating an incentive payment for brokers who help enroll people in high-quality, value-based plans.
The MA for Tomorrow policies would establish limits on plans’ payments to such organizations, beef up repercussions for misleading marketing, and reduce the quantity of marketing materials enrollees receive. These policies build on the ones included in CMS’ recently finalized MA rule, ACHP says.
CMS on April 5 finalized an array of MA marketing reforms for the upcoming 2024 Medicare open enrollment season, including plans to crack down on general television advertisements after concerns over such marketing kicked into high gear last year. CMS said it was worried about marketing practices last fall, including from third-party marketing organizations and television advertisements.
MA for Tomorrow also calls for changes to the risk adjustment model, including basing risk adjustment on MA encounter data rather than on encounter data from traditional Medicare.
ACHP pointed to a report from the Medicare Payment Advisory Commission that found plans could earn more per beneficiary through frequent high-intensity coding than they can through quality bonuses, which ACHP says is a problematic incentive.
A recalibrated system would improve payment accuracy by using MA claims data on diagnoses, treatment and services – and the change could be accomplished under CMS’ existing authority, ACHP says.
CMS should also reorganize its auditing processes on Risk Adjustment Data Validation (RADV) to target outlier plans with track records of coding abuses or a higher likelihood of upcoding, which would help the agency make more efficient use of its resources and funding, ACHP says.
ACHP also says CMS should also consider including a tiered coding intensity adjustment to cut down on differences in coding among plans.
Coding intensity has generated an increasing amount of payment inequity, MedPAC staffers said in January: Between 2007 and 2023, MA coding intensity generated nearly $124 billion in excess payments to MA plans, including about $80 billion between 2007 and 2021 and an anticipated $44 billion in 2022 and 2023. -- Bridget Early (bearly@iwpnews.com)
