Radar on Medicare Advantage

CMS Emphasizes Member Experience in Star Ratings

July 9, 2020

CMS, building on its multi-year theme of emphasizing member experience within Medicare Advantage (MA), is increasing the weight of member experience measures beginning with the 2021 star ratings.

“CMS is really emphasizing the patient experience and the patient’s perception of their care, both from the plan and with the plan’s provider network,” says Melissa Smith, senior vice president, stars and strategy for Gorman Health Group. “[T]his is the first time that we’re really disproportionately going to see [patient experience] weigh on stars.”

By Jane Anderson

CMS, building on its multi-year theme of emphasizing member experience within Medicare Advantage (MA), is increasing the weight of member experience measures beginning with the 2021 star ratings.

“CMS is really emphasizing the patient experience and the patient’s perception of their care, both from the plan and with the plan’s provider network,” says Melissa Smith, senior vice president, stars and strategy for Gorman Health Group. “[T]his is the first time that we’re really disproportionately going to see [patient experience] weigh on stars.”

With the changes, 32% of the star rating will represent member perceptions, Smith tells AIS Health.

“This has been coming for a while, and plans — particularly the more thoughtful and progressive plans that are out there — really have started to make this a way of doing business,” adds Matt Siegel, specialist leader, Deloitte LLP.

CMS now will emphasize measures in which many plans historically have struggled, Smith says. In fact, the two areas in which plans struggle most are the Consumer Assessment of Healthcare Providers & Systems (CAHPS) and the Health Outcomes Survey, and beginning in 2021, those two surveys will be worth a combined 41% of the overall rating, Smith says.

To prepare for this changes, MA plans will need to “take a very hard look at what they’re selling, how they’re packaging it and communicating it to the consumer, and then how effectively they’re acting upon what they promised the consumer they’re going to get,” Smith says.

To succeed in the new member experience-weighted star system, MA plans will need to consider star ratings and member experience in almost every aspect of their organizations, and incentivize, manage and measure staff performance, Siegel adds.

Akhil Rao, manager at Deloitte Consulting, says he expects “a seismic shift in how plans will be impacted.” Some plans are doing well in the CAHPS survey, and many of those also are 5-star plans. Those could continue to perform well once CAHPS results make up a far larger percentage of their overall stars rating, he adds.

CMS Report Shows Increasing Racial Disparities in MA Plans

June 22, 2020

As protests erupt across the U.S. calling for racial justice and police reforms, the COVID-19 pandemic continues to bring to light many of the racial disparities in health care, putting pressure on policymakers and the industry to take a hard look at health and access inequities.

Meanwhile, CMS’s Office of Minority Research in April released a stratified report highlighting the racial and ethnic differences in health care experiences and care of Medicare Advantage (MA) enrollees. The data showed that black members enrolled in MA plans in 2018 received worse clinical care than white enrollees on 20 out of 44 measures, similar care for 20 and better care for four. And all minority populations reported experiences with care that were either worse than or similar to the experiences reported by white enrollees, including the experience measure for getting appointments and care quickly.

By Lauren Flynn Kelly

As protests erupt across the U.S. calling for racial justice and police reforms, the COVID-19 pandemic continues to bring to light many of the racial disparities in health care, putting pressure on policymakers and the industry to take a hard look at health and access inequities.

Meanwhile, CMS’s Office of Minority Research in April released a stratified report highlighting the racial and ethnic differences in health care experiences and care of Medicare Advantage (MA) enrollees. The data showed that black members enrolled in MA plans in 2018 received worse clinical care than white enrollees on 20 out of 44 measures, similar care for 20 and better care for four. And all minority populations reported experiences with care that were either worse than or similar to the experiences reported by white enrollees, including the experience measure for getting appointments and care quickly.

Not getting the proper care when it’s needed is a reflection of the provider network, says John Gorman, chairman and CEO of Nightingale Partners LLC. “And then when you look at the clinical measures where there’s huge racial disparities, all of those tie back to a lack of culturally competent physicians serving these populations in a manner that speaks to the way that they need to access health care,” he observes.

John Weis, president and co-founder of Quest Analytics, LLC, predicts that “there will be a significant impact on practice consolidation” from the pandemic. “Given the potential risk to providers, we predict that coming out of COVID, we’ll see an uptick in providers that want to minimize their exposure and consider retirement,” he suggests. And with fewer providers available, “if plans are not prepared, this will drive both out-of-network utilization and increase health care costs in rural areas.”

Dan Mendelson, founder of Avalere Health, suggests that while MA plans have the tools to address racial disparities, they don’t necessarily have the incentives to prioritize them. “I think Medicare Advantage plans are uniquely equipped to measure, understand, identify and mitigate disparities…. So, a proactive form of engagement that is focused on disparities can work,” says Mendelson. “One thing that is not there at this point is any kind of direct incentive to the plans to act.”

2021 MA, Part D Bids Face Challenges Amid COVID-19

June 8, 2020

There are always uncertainties when it comes to projecting plan costs for the year ahead, but Medicare Advantage and Part D organizations that submitted bids on June 1 faced a particularly unpredictable set of circumstances created by the COVID-19 pandemic.

“I think we will all look back on the 2021 bids as the year of COVID-19,” says Brad Piper, a principal and consulting actuary in Milliman’s Milwaukee office. “That was a big challenge for the organizations that are in the Medicare Advantage program — [perhaps more so] than on the Part D side — and it impacted both sides of the coin: costs and revenue.”

By Lauren Flynn Kelly

There are always uncertainties when it comes to projecting plan costs for the year ahead, but Medicare Advantage and Part D organizations that submitted bids on June 1 faced a particularly unpredictable set of circumstances created by the COVID-19 pandemic.

“I think we will all look back on the 2021 bids as the year of COVID-19,” says Brad Piper, a principal and consulting actuary in Milliman’s Milwaukee office. “That was a big challenge for the organizations that are in the Medicare Advantage program — [perhaps more so] than on the Part D side — and it impacted both sides of the coin: costs and revenue.”

From a cost perspective, unknowns include whether there will be “pent-up demand” for health care services next year given that many beneficiaries have deferred doctors’ appointments and elective/non-urgent procedures to avoid the risk of coronavirus exposure.

Adding to that is the question of whether there will be a second wave of COVID-19 “and how much COVID-related utilization and services will occur that plans will have to bear,” points out Matt Kazan, principal with Avalere Health. A third concern is “how much of the cost of all the things Congress is saying plans will need to cover in terms of testing, vaccines…will impact plans,” says Kazan, referring to various legislative requirements, some of which are still pending.

Preparing bids on the revenue side was equally challenging, since it’s the 2020 diagnosis information that drives reimbursement for next year, adds Piper. “As we’re trying to forecast what 2021 revenue will look like, we’ve got to look at what’s going on in today’s environment and understand if we’re not seeing our members as often…that potentially creates a challenge for health plans to capture all that diagnosis information in 2020, which in turn drives their 2021 revenue amount.”

On the Part D side, Milliman principal and consulting actuary Shelly Brandel says COVID-19 had less of an impact on costs because prescription drug utilization or fills weren’t “delayed to the same degree as medical services had been.” The risk score impact, however, created a similar challenge because Part D risk scores are based on medical diagnoses, she adds.

Nonwhite, Disabled Enrollees Are More Likely to Switch from MA to FFS, Study Shows

May 27, 2020

Previous research has suggested that disabled adults who rely on services such as home health and nursing home care are more likely to switch from Medicare Advantage to traditional, fee-for-service (FFS) Medicare. Now, a new study appearing in Health Affairs confirms researchers’ assumptions that such switching is more prevalent among MA beneficiaries who are nonwhite and/or from vulnerable sociodemographic groups.

Researchers from the Icahn School of Medicine at Mount Sinai in New York City and the University of California San Francisco examined five years of data from the National Health and Aging Trends Study to assess switching between MA and traditional Medicare 12 months before and after the onset of a disability.

By Lauren Flynn Kelly

Previous research has suggested that disabled adults who rely on services such as home health and nursing home care are more likely to switch from Medicare Advantage to traditional, fee-for-service (FFS) Medicare. Now, a new study appearing in Health Affairs confirms researchers’ assumptions that such switching is more prevalent among MA beneficiaries who are nonwhite and/or from vulnerable sociodemographic groups.

Researchers from the Icahn School of Medicine at Mount Sinai in New York City and the University of California San Francisco examined five years of data from the National Health and Aging Trends Study to assess switching between MA and traditional Medicare 12 months before and after the onset of a disability.

They found that 10.6% of people who were initially in MA switched to traditional Medicare and that the incidence of switches per 1,000 person-years climbed from 53.5 before disability to 65.6 after disability.

The authors also observed that nonwhite respondents had higher rates of switching both before and after disability — particularly those who started in MA plans. Before disability onset, those who were in MA plans had 94.3 vs. 63.6 switches per 1,000 person-years for those in traditional Medicare. The rates after disability were 81.9 vs. 71.0 switches per 1,000 person-years.

“One potential reason why a person with special needs or other chronic conditions may switch to fee-for-service Medicare is the network,” observes Matt Kazan, a principal with Avalere Health. If patients are diagnosed with a new disease and then discover that the providers they need aren’t in network, they tend to move to open-network FFS.

But switching out of MA plans “may have unanticipated financial impacts on patients, given that in most states Medigap plans to supplement traditional Medicare coverage can refuse coverage to those with preexisting conditions if a person is not new to Medicare,” pointed out the study’s authors.

Kazan says it would be interesting to see study results using more current data given that from 2011 to 2016, certain Affordable Care Act payment and risk adjustment changes were being phased in, and MA beneficiaries now have access to more home-based supports thanks to CHRONIC Care Act provisions contained in the Bipartisan Budget Act of 2018.

MA Insurers Are Positioned to Assist the Suddenly Uninsured

May 11, 2020

As seniors during the coronavirus pandemic face issues such as loneliness, social isolation and food insecurity, an added source of stress for some may be trying to enroll in Medicare. And Medicare Advantage plans are uniquely positioned to educate people over the age of 65 who may qualify for a Medicare special enrollment period (SEP).

“People who have other coverage when they become eligible for Medicare have even more to wade through, like whether Medicare will pay primary or secondary, and whether they have access to any other enrollment windows. The answers are different for each type of insurance and situation,” explained Medicare Rights Center Federal Policy Director Lindsey Copeland in a blog post. “The considerations are dizzying, and the stakes are high.”

By Lauren Flynn Kelly

As seniors during the coronavirus pandemic face issues such as loneliness, social isolation and food insecurity, an added source of stress for some may be trying to enroll in Medicare. And Medicare Advantage plans are uniquely positioned to educate people over the age of 65 who may qualify for a Medicare special enrollment period (SEP).

“People who have other coverage when they become eligible for Medicare have even more to wade through, like whether Medicare will pay primary or secondary, and whether they have access to any other enrollment windows. The answers are different for each type of insurance and situation,” explained Medicare Rights Center Federal Policy Director Lindsey Copeland in a blog post. “The considerations are dizzying, and the stakes are high.”

“As the COVID-19 crisis unfolds, Medicare marketers across the country find themselves in a unique position to aid a group of individuals who they serve and who need their immediate help,” suggests a client briefing from marketing agency DMW Direct.

Independence Blue Cross, for example, says it has modified its New to Medicare approach in direct mail, digital and social media campaigns and, when applicable, is able to engage through its broker partners existing members who have lost commercial coverage with the insurer.

The biggest challenge the insurer has observed for this group is having to navigate through Social Security, particularly if individuals only need to add Part B coverage as a “late retiree,” says Kortney Cruz, vice president of Medicare sales and marketing at the insurer.

Medicare Rights Center has issued letters to CMS and Congress asking them to extend currently available Medicare enrollment periods by establishing a new SEP or re-opening and extending the general enrollment period. CMS at press time issued a notice to all MAOs, Part D sponsors and Medicare-Medicaid Plans clarifying that the “exceptional conditions” SEP for Individuals Affected by a FEMA-Declared Weather Related Emergency or Major Disaster applies under the current circumstances. The May 5 memo from the Medicare Enrollment & Appeals Group said the SEP is available to beneficiaries who meet certain criteria and who were eligible for — but unable to make — an election because they were affected by the pandemic.