A team of healthcare policy researchers, in an article published this month in The New England Journal of Medicine, is arguing for a dramatic overhaul of the Medicare Advantage program, in order to move the program forward on quality measurement, transparency, and non-medical support for Medicare Advantage plan members. The authors of the article, published online on May 11, and entitled “Addressing Serious Illness Care in Medicare Advantage,” believe that some of the core systems of measurement, evaluation, and even information, involved in the program, need to be drastically overhauled in order to address MA enrollees living with serious chronic illness. The authors are Claire K. Ankuda, M.D., M.P.H., Melissa D. Aldridge, Ph.D., M.B.A., R. Tyler Braun, Ph.D., Norma B. Coe, Ph.D., David C. Grabowski, Ph.D., David J. Meyers, Ph.D., M.P.H., Andrew Ryan, Ph.D., David Stevenson, Ph.D., and Joan M. Teno, M.D.
They begin by noting that, “With 48 percent of Medicare beneficiaries enrolled in the Medicare Advantage program, the challenge of providing high-quality care for people with serious illness who are covered by such plans is pressing. Though it previously insured healthier beneficiaries than did traditional Medicare, on average, Medicare Advantage increasingly insures people with serious illness under special-needs plans that cater to beneficiaries who are dually eligible for Medicare and Medicaid, those residing in institutions, and those with certain chronic illnesses. Medicare Advantage enrollment has grown disproportionately among Black and Latinx people, so any quality deficiencies in the program may result in racial and ethnic disparities in quality of care and outcomes.”
What’s more, the article’s authors note, “Although competent, equitable, and person-centered, plan administrators face financial incentives to contain costs, since they receive capitated payments and therefore may keep a portion of payments as profit. For enrollees with serious illness, who often require extensive care provided in multiple settings, the 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. We believe a comprehensive approach that prioritizes improving data transparency and quality measurement is necessary to ensure that the Medicare Advantage program facilitates the delivery of high-quality and equitable care.”
As they write, “There are several challenges involved in improving the quality of care in Medicare Advantage for people with serious illness. Despite the program’s substantial growth, there aren’t sufficient data to evaluate the quality of care delivered to beneficiaries with serious illness, much less to assess disparities based on race, region, or dual-eligible status. For 3 consecutive years, the Medicare Payment Advisory Commission (MedPAC), on which one of us recently served, stated that it “can no longer provide an accurate description of the quality of care in [Medicare Advantage].”2 Although plan-reported encounter data are now released to researchers, they are neither complete nor reliable,3 which makes assessing service delivery challenging.”
The researchers suggest several sweeping changes that they believe need to be made in the Medicare Advantage program in order to address what they see as those deficiencies, among them: totally reworking the supplemental benefits element within Medicare Advantage so that such benefits—including meal, transportation, and caregiver-support benefits—can be systematically tracked and analyzed for the value of their support to MA members; a total reworking of the Quality Bonus Program—QPB—inside MA, with strong efforts to improve the quality and accuracy of the five-star rating system on which it is based; and the creation of transparency of information so that plan members and others can fairly assess the cost-sharing structures, supplemental benefits, and provider networks that are offered to Medicare-eligible people for voluntary enrollment.
Indeed, the authors conclude, “We believe several strategies could help address the concerns associated with current efforts to report on quality of care in Medicare Advantage (see table). These challenges are complex, however, and multiple stakeholders will need to contribute to developing the best approaches to confronting them. Congress could commission a report from the National Academies of Sciences, Engineering, and Medicine on quality of care in Medicare Advantage, with a focus on people needing complex and high-cost care, particularly those with serious illness.” And they end by stating that “Our concerns regarding care delivery for Medicare Advantage enrollees have been previously raised and echo years of analysis by researchers and MedPAC. Nevertheless, with the program projected to enroll up to 60% of Medicare beneficiaries by 2030, urgent reevaluation is needed. We believe the time has come for a forward-thinking approach aimed at reforming Medicare Advantage to better meet the needs of people with serious illness.”
