Medicare Advantage organizations must help reduce burden on doctors, American College of Physicians says

Male doctor in white lab coat
“As Medicare moves away from its traditional fee-for-service and toward the Quality Payment Program linking physician payment to high-value care, it is a critical time for the MA program to make improvements,” says American College of Physicians President Jack Ende. (Getty/Saklakova)

The country’s largest medical specialty organization is calling on Medicare Advantage organizations to help make physicians’ lives a bit easier.

The best way to do that, argues a new policy paper (PDF) from the American College of Physicians, is to promote more transparency and alignment among MA plans.

“If MA plans were to increase transparency that would give the Centers for Medicare & Medicaid Services the opportunity to examine them more closely and promote alignment, thus lessening the administrative burden associated with clinician participation in these plans,” said ACP President Jack Ende, M.D.

“As Medicare moves away from its traditional fee-for-service and toward the Quality Payment Program linking physician payment to high-value care, it is a critical time for the MA program to make improvements,” he added.

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To promote those improvements, the policy paper recommends that MA organizations:

  • Increase transparency and alignment in their administrative processes, contracting arrangements with participating physicians, and processes and requirements for risk stratification and capturing severity of illness.
  • Engage physicians in the design and implementation of value-based payment models, and encourage models that allow clinicians to share in the savings.
  • Take steps to reduce excessive administrative tasks placed on physicians and beneficiaries who participate in MA plans.

The ACP also had several recommendations for policymakers and regulators, calling on them to:

  • Align the performance measurement system across Medicare programs and the commercial insurance market.
  • Conduct research that compares the types of payment models used and prices paid by MAOs to providers with the models used and prices paid by traditional Medicare and commercial health insurance plans.
  • Continue two policies that were enacted under the Affordable Care Act, which ensure that MA plans are funded at the same level of the traditional Medicare program, and require that at least 85% of MA organizations’ revenue goes toward patient care.
  • Encourage independent entities like the Office of Inspector General to investigate potentially fraudulent activity and the misuse of risk stratification by MA plans, and hold those plans—not participating physicians—accountable if fraudulent activity is uncovered.

Indeed, the increasing popularity of private Medicare plans has come with increased scrutiny of how insurers administer them.

Cigna recently emerged from a CMS sanction that banned the insurer from selling new Medicare products after the agency identified multiple compliance violations. And in recent months, the Justice Department has joined two whistleblower lawsuits that accuse UnitedHealth of engaging in fraudulent risk adjustment practices—accusations that the insurer has denied.

At the same time, though, MA organizations have stepped up their game to lower costs and increase quality in order to improve their star ratings from CMS.