AHIP 2024: Cutting through the 'nostalgia' for traditional Medicare

LAS VEGAS—The eyes of many regulators and lawmakers are on Medicare Advantage (MA), and, amid rising criticism of the program, one industry leader is making the case that "nostalgia" for traditional Medicare is misguided.

Sachin Jain, M.D., is CEO of SCAN Group, which offers MA coverage in five states. He submitted a commentary to JAMA Internal Medicine earlier this month that aims to refute commonly cited concerns with MA and posit that the traditional program also has plenty of issues.

The article is a response to another JAMA Internal Medicine piece that describes MA as "less care at a higher cost."

"I kind of was like, you know, a lot of what they say about Medicare Advantage is true, but why are we giving traditional Medicare a free pass?" Jain told Fierce Healthcare in an interview at AHIP 2024 last week. "If you actually then look at it through the lens of the original initial intent of the program, the program that aligns most clearly with the original intent of Medicare is Medicare Advantage."

For instance, the original article dings MA for tight networks and other utilization management techniques. Jain argued, however, the lack of these cost containment measures in traditional Medicare incentivizes providers to "provide as much care as possible, whether or not that care is beneficial or grounded in clinical evidence."

Jain said in the interview that MA is far ahead of traditional Medicare in terms of driving value and also has quality measurements that are made clear to members in the form of the star ratings.

"At least we have a functioning quality measurement program that's consumer friendly," Jain said. "What's the star rating of traditional Medicare?

Jain does acknowledge, though, that there are areas where MA can continue to improve. Risk adjustment, for example, is a "necessary evil of the system," though regulators can and should respond to mitigate any abuse, which MA plans have taken heat for.

In the paper, he wrote that the Centers for Medicare & Medicaid Services (CMS) should continue efforts around coding that can align MA outlays more closely to traditional Medicare.

In addition, CMS can look at areas where MA plans have gone too far in designing unique benefits to reach consumers. MA gives insurers significant leeway to innovate around benefits, but offerings like Part B rebates carry limited value for members.

Standards that currently exist for supplemental Medicare coverage could serve as an inspiration, Jain wrote.

Jain also argues that CMS could and should test additional models in MA through its Innovation Center. One potential pilot? A multiyear enrollment program that would allow enrollees to stay in the same plan for the long haul could allow for more intensive care coordination and management.

Jain told Fierce that he's been advocating for policies that support three- or five-year enrollment cycles.

"I think that'll actually stimulate the digital health and health innovation ecosystem, because so many innovators have this problem of having to demonstrate ROI in 12 to 18 months," he said.