RISE reviews recent reports and studies that look at aspects of Medicare Advantage (MA).
Urban Institute calls for overhaul of MA quality bonus program, recommends new policies
A new report by the Urban Institute finds little evidence that Medicare pay-for-performance (P4P) and public reporting programs have driven improvement in clinical or administrative performance despite the high cost of these programs. Indeed, the report determines that P4P has serious operational flaws and produces adverse effects.
The quality bonus program aims to provide incentives to MA plans to improve quality and help members select high-quality plans. But the report argues that the program has failed to achieve these goals yet spending on bonuses to “high-quality” MA plans now exceeds $10 billion per year.
Report authors recommend three policies to replace the current quality bonus program:
- Implement stricter CMS oversight of MA plans to ensure adherence to contractual obligations and concentrating on demonstrated substandard performance, like prior authorization and claims denials.
- Use a limited number of validated quality measures to identify exceptional and poor MA plan performance. These measures would focus on prevention activities, patient-reported outcomes, and patient experiences with their health plan. Measurement would be limited to identifying exceptionally strong and poor performance, not broadly rating or ranking MA plans, and need not be made public.
- Replace the current quality bonus program with one that encourages or requires MA plans to implement quality improvement projects or adopt continuous quality improvement methods.
In addition, authors recommend establishing a task force to develop specific policy recommendations for Congress and the Centers for Medicare & Medicaid Services (CMS). Task force members should include quality experts, clinical leaders from MA plans, and consumer/beneficiary representatives.
Chartis report: MA enrollment remains strong despite slowing growth and regulatory headwinds
Chartis’ annual MA competitive enrollment report reveals that despite decelerating growth, most plan leaders are optimistic about the next five years, expecting neutral or positive overall outcomes. The 2024 report analyzed CMS MA and Medicare fee-for-service enrollment data from January 2019 to January 2024 and surveyed 19 health plan executives from leading MA plans. Eighty-four percent of the executives anticipate membership growth equal to or greater than the current year, indicating confidence in the stability and growth potential of the market.
The MA market grew by 1.7 million beneficiaries in 2023, slowing down from the record growth of 2.7 million in 2022, according to the report. The enrollment growth is fueled by an increasing senior market but is overshadowed by regulatory pressures, declining quality scores, and rising medical costs.
“While the Medicare Advantage market has matured significantly over the past several years, demand for these plans persists because of changing demographics and continued consumer attraction compared to Original Medicare,” said Nick Herro, director in strategic transformation and co-author of the report, in the announcement.
Alexis Levy, managing director at HealthScape Advisors and report co-author, said that health plans have made significant investments to respond to the growth opportunity but now they face a challenging market, increased competition, and regulatory pressures. “This new market landscape requires stakeholders to diversify offerings, optimize member engagement, and create sustainable growth and performance,” Levy said in the announcement.
In addition to top-line enrollment statistics and executive sentiment, the report analyzed special needs plan growth, plan options and preferences, market dynamics and quality, and deeper trends driving the top-line data. Click here to view the full report.
Study: MA plans less effective for home health care than traditional Medicare
MA patients receive fewer home health visits and have worse outcomes compared with traditional Medicare recipients, according to a study of nearly 300,000 Medicare beneficiaries published in JAMA Health Forum.
“Across the board, patients with Medicare Advantage plans are getting less home health care,” said lead author Rachel Prusynski, an assistant professor of rehabilitation medicine and a researcher at the University of Washington School of Medicine's Center for Health Workforce Studies, in the study announcement.
Prusynski was awarded a grant to study data provided by a large home health operator. The research team examined anonymous patient information from 2019-22 for more than 285,000 home health recipients 65 or older. The data spanned 102 home health company locations in 19 states.
The team found that MA patients had shorter home health lengths of stay, fewer visits by nursing and therapy clinicians and home health aides, lower rates of improvement in self-care and mobility function, and higher rates of discharge to the community from home health.
The authors said that higher rates of community discharge, combined with lower functional improvement, may adversely affect patients’ independence, and increase their caregivers’ burden for people with MA coverage.
“We know that the amount of cognitive impairment or the amount of help a patient has at home really impacts their outcomes,” Prusynski said. “We were able to robustly adjust for some of those differences and started to see that these challenges in the health system are trickling down to patients—and that Medicare Advantage is limiting some care. That is not only providing money for the health insurance companies, but it is making care outcomes potentially worse for patients.”
Data showed that MA patients had three percent lower odds of improving mobility, four percent lower odds of being able to care for themselves and were five percent more likely to be discharged to the community despite less functional improvement. MA patients received 1.62 fewer days length of treatment on average.
“These are small percentages, but we controlled for all the differences between these two patient populations,” Prusynski said. “Even if patients had the same level of medical complexity, the same challenge getting around their house, the same level of support at home, the same caregiver support—even comparing apples to apples—Medicare Advantage patients still got fewer services and they didn't improve in their functional scores as much as traditional Medicare patients.”
The researchers’ findings, Prusynski said, support assertions that MA plans appear to ration the clients’ care, including home health, and to be oriented more toward profitability than patient well-being.