A new-look Medicare Advantage (MA) quality bonus program would better incentivize insurers and help individuals choose a more appropriate plan, a report from Urban Institute finds.
Authors Robert Berenson, M.D., and Laura Skopec spoke with six experts on how to best improve the program. They said that while public reporting programs don't seem to have improved clinical or administrative performance, and bonus payments to high-performing plans now exceed $12 billion per year, there are several policies that could help.
First, the paper argues for stronger oversight of MA plans. It details a laundry list of items where MA could improve—prior authorization delays, predatory marketing practices and limited provider directories to name a few—by establishing more robust enforcement functions, something the Centers for Medicare & Medicaid Services (CMS) has already begun to address. They want the agency to go further by utilizing tactics like audits, enrollment freezes and program expulsion more often.
"Currently, MA plans are overpaid to provide services with known deficiencies," said the authors. "Rather than continue to adjust the QBP, CMS efforts should focus on correcting overpayment and abuses in the MA program."
The report also calls for reducing the number of quality measures as well as no longer publicly reporting a plan's star ratings score. The shift would instead focus time and attention toward the top and bottom 5% of plans, removing MA plans' pressure to focus resources on a limited set of measures.
An enhanced administrative oversight program would investigate poor performance, but top plans would be identified through population health and preventive services measures. This would be achieved through claims and encounter data, and plans would be judged against each other at the local level.
"In a major change of philosophy, plans should be encouraged to collaborate more with each other and the traditional Medicare program to implement quality initiative activities, as permitted under antitrust law, rather than being pitted against each other," the authors added.
Finally, experts did not agree on whether plans are able, or should, help advance clinical quality improvement. Still, they recommended to replace the current external performance measurement with a program that requires MA plans to establish quality improvement projects.
"Because MA plans contract with hundreds or even thousands of clinicians and other providers, they can achieve substantial quality improvement by committing to continuous quality improvement," the report said. "We recommend that CMS encourage a shift in focus toward continuous quality improvement strategies over which MA plans have direct control rather than assessing MA performance largely by the performance of their contracted providers, who also contract with numerous other payers."
It also calls on plans to work with other providers and insurers to participate in quality improvement projects, such as a program to improve high blood pressure among beneficiaries or to address diagnosis errors in hospitalized adults, the report said.
The authors say a dedicated task force that recommends policy to CMS that includes quality experts and beneficiary representatives is another potential solution.
A previous report from the left-leaning think tank said that the program fails to properly reward plans that improve quality and doesn't encourage beneficiaries to use the rating system when shopping for healthcare services. Berenson and Skopec at the time suggested CMS change the system to value contract- and state-level reporting as well as to lower the number the plans that can achieve a 4-star rating or better.
The quality bonus program was established by the Affordable Care Act. Measures include clinical quality, administrative performance and patient experience measures. These measures are weighted and assigned a star rating that can have major implications on future year plan performance.