RISE summarizes this week’s regulatory-related news.

Brookings essay urges CMS to ditch plans for ‘two-stage’ risk adjustment in ACA marketplace

A new paper calls for the Centers for Medicare & Medicaid Services (CMS) to abandon its proposal  for the Affordable Care Act (ACA) marketplace to use atwo-stage” estimation procedure to set risk scores. The proposal would increase risk scores for lower-risk enrollees and reduce them for higher-risk enrollees.

“As a result, insurers that tend to attract lower-risk enrollees would pay less into risk adjustment, while insurers that attract higher-risk enrollees would receive less,” write Matthew Fiedler, Ph.D., fellow-economic studies, USC-Brookings Schaeffer Initiative for Health Policy, and Timothy Layton, Ph.D., 30th anniversary associate professor of health care policy, Department of Health Care Policy, Harvard Medical School, in the essay. The paper is part of the USC-Brookings Schaeffer Initiative for Health Policy, a partnership between the Economic Studies Program at Brookings and the USC Schaeffer Center for Health Policy and Economics.

The authors argue that the CMS proposal would drive enrollees toward skimpier plans, raise premiums for higher-risk enrollees, and potentially reduce competition. Changes to risk adjustment are warranted, they write, however, the proposals should aim to increase payments to insurers with higher-risk enrollees.

“We believe that improving risk adjustment will require CMS to change its focus,” they write. “Rather than focusing narrowly on changes that would improve model fit at the enrollee level—and improve fit for low-risk enrollees in particular—CMS should focus on how to ensure that risk adjustment transfers are aligned with differences in claims risk at the plan level, including differences in risk that may not be directly captured in risk scores.”

Click here to read the paper in its entirety.

MSSP: Participation increases slightly, NAACOS calls for CMS to spur growth in program

Sixty-six new accountable care organizations (ACOs) joined the Medicare Shared Savings Program (MSSP) and 140 existing ACOs renewed their participation in the program starting January 1, 2022, according to CMS. This brings the total number of ACOs in the Medicare national program to 483 in 2022.The agency projects that more than 11 million people with Medicare will be served by MSSP ACOs in 2022, a 3 percent increase from the previous year.

Shared Savings Program ACOs are groups of doctors, hospitals, and other health care providers who join voluntarily to give coordinated high-quality care to Medicare beneficiaries and ensure that people receive the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO may be eligible to share in the savings it achieves for the Medicare program. In certain instances, an ACO may owe a portion of losses if it increases costs or does not meet certain quality metrics.

Although CMS said the program continues to grow and deliver high-quality, person-centered care, the National Association of ACOs (NAACOS) said the agency’s announcement should be a wake-up call to the administration to do something if it aims to achieve its goal to have all traditional Medicare patients in an accountable care model by 2030.

The CMS announcement is “disappointing,” NAACOS said in a statement, noting that it followed multiple years of flat or declining ACO growth. “There are still fewer patients in ACOs and ACOs in the program than there were in 2020.”

ACOs have saved Medicare $13.3 billion in gross savings and $4.7 in net savings since 2012, the association said.

The association called for policymakers to address incentives to spur participation in the voluntary program. To attract new ACOs and retain existing ones, the NAACOS suggests Medicare increase ACO shared savings rates, fix key benchmarking and risk adjustment issues, allow more time before requiring risk, minimize administrative burdens, rethink quality reporting requirements, and provide more timely and complete data.

KFF policy watch report on whether largest MA insurers cover the cost of at-home COVID tests

In the wake of the federal government requiring private insurers to cover the cost of at-home COVID tests, the Kaiser Family Foundation (KFF) recently conducted a review to determine whether Medicare Advantage (MA) plans are covering the cost of at-home COVID tests.

The government policy does not apply to Medicare. However, MA plans, which are offered by private insurers, have the option to cover at-home tests.

KFF reviewed websites and spoke with customer service representatives of five of the largest MA insurers (Kaiser Permanente, UnitedHealthcare, Humana, CVS Health, Cigna). They found:

  • Four of the five MA insurers are not reimbursing enrollees for at-home tests (only Kaiser Permanente is providing coverage of up to eight at-home tests per month for both their Medicare and private enrollees)
  • One of the five insurers (Kaiser Permanente) will reimburse members for the cost of rapid antigen home tests
  • Three of the five insurers (Humana, CVS Health, Cigna) state on their website that the new at-home testing reimbursement policy does not apply to people on Medicare
  • UnitedHealthcare states on its website that their “Medicare Advantage members are not eligible for reimbursement of OTC, at-home COVID-19 tests purchased without a physician’s order, but that most of the issuer’s MA plans have an OTC benefit that can be used to get OTC at-home COVID-19 tests