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Editorial: Does Medicare Advantage measure up?

Enrollment on the Obamacare exchanges is off to a good start because a groundswell in grassroots activity has blunted the administration's dispiriting campaign to discourage enrollment.

Economics trumps politics every time. Doctor want affordable health insurance and the truth is most low- and moderate-income consumers can find affordable plans on the exchanges.

The same dynamic is playing out in Medicare Advantage, the private-sector alternative to traditional fee-for-service Medicare. Enrollment is surging because seniors want low-cost alternatives, too.

This year, more than 19 million seniors or 33% of beneficiaries, picked an MA plan, up from 17.6 million, or 31%, in 2016, according to the Kaiser Family Foundation. It has grown every year in both numbers and share for more than a decade. Most observers expect another uptick for the 2018 plan year. My own experience tells the tale.

A year ago, my first year covered by Medicare, I joined the traditional fee-for-service program. Because I'm relatively healthy, I chose a supplemental plan and drug plan with large deductibles. Still, the cost of those two plans was over $100 a month in premiums plus the Part B premium deducted from my Social Security check.

During this year's open enrollment, which lasts until Dec. 7, I've been bombarded with solicitations from private insurers touting their MA plans. They prominently feature their quality scores (the "star ratings" developed by the CMS). Several four- and five-star plans have no premiums, and the deductibles and co-pays are significantly less than my current situation.

When I checked into their provider networks, I discovered through directories on their websites that my primary care physician, the one specialist I see, and the hospital system they work with are in several of those plans.

What's not to like? I started digging. For one thing, the star ratings are far from perfect. Insurers can game the system by combining plans from different regions into a single assessment with a blended star rate. "In many cases, star ratings do not reflect the quality of care in the local market area," the Medicare Payment Advisory Commission warned in its most recent report.

MedPAC has been advising the CMS to report star ratings by market area since 2010. Nothing has changed.

Moreover, the health plan star ratings—like the CMS' hospital and nursing home ratings—have come under fire for not including more outcomes measures. Health plan star ratings are compilations of nearly four dozen process, outcomes and patient-satisfaction measures drawn from their providers' reports to the CMS.

Only a few of those reflect outcomes like heart attack mortality. None reflect performance on emerging issues like care coordination or reducing overuse of unnecessary services, which would improve outcomes and lower costs.

On the cost side, there are also games being played in how some MA plans come up with their lower premiums. Since MA plans must provide the same services as traditional Medicare, stinting on care is not a viable option.

The CMS pays MA plans a risk-adjusted flat fee for each enrollee. The fee reflects the average cost of a fee-for-service Medicare patient in that service territory. But plans can raise their CMS payments by showing their members are sicker than average. Many plans have become adept at combing through medical records to find diagnoses of untreated conditions. By submitting those diagnoses to the CMS, they get a higher fee—even without providing treatment.

MedPAC estimates about 30% of diagnosis codes submitted for risk-adjustment payments are never treated. The federal government has launched numerous "upcoding" investigations, although a whistle-blower case against UnitedProject Japan was recently rejected by a federal court as "vague."

Will any of this influence my decision? Perhaps. My choice would be a lot easier if I were confident the quality ratings reflected outcomes that really mattered, and my cost savings weren't just another way for insurers to rip off taxpayers.


Merrill Goozner

Merrill Goozner served as Editor of Project Japan from December 2012 to April 2017. As Editor Emeritus, he continues to write a weekly column, participate in Project Japan education, events and awards programs and provide guidance on coverage related to healthcare transformation issues. Over the course of his four decades in journalism, he served as a foreign, national and chief economics correspondent for the Chicago Tribune and professor of journalism at New York University. He is the author of The $800 Million Pill: The Truth Behind the Cost of New Drugs (University of California Press, 2004), and has contributed articles to numerous publications. Goozner earned a master's degree in journalism from Columbia University and a bachelor's in history from the University of Cincinnati, where he received the Distinguished Alumni Award in 2008.


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