HLTH23: Experts debate the flaws, future of Medicare Advantage

LAS VEGAS—Medicare Advantage (MA) has only grown over the last decade, and, in tandem, voices criticizing the program have gotten louder.

But can the faults in MA be solved, or is the answer to scrap the program entirely? That topic was up for debate Monday during HLTH, where SCAN Group CEO Sachin Jain, M.D., and consultant Rick Gilfillan, M.D., sat down on the main stage to discuss the Wild West of MA.

Both Jain and Gilfillan have experience at the Centers for Medicare & Medicaid Services as well as in both the payer and provider worlds. Gilfillan most recently served as CEO of Trinity Health, departing the health system in 2019.

Jain said that while there are significant concerns with how MA operates today, the program has a solid foundation that can support change. However, that change will likely need to start within healthcare rather than waiting for Congress to take it on.

"I think it's up to us right now to take a look at these programs and try to make them better in service of people who need these things," he said. "But I think we have a chassis that can be saved, its flaws notwithstanding."

Gilfillan took a less kind view of the program, however. While acknowledging that it's likely an "unrealistic" plan, he said MA should come to an end, as it has outlived its intended goals.

Many low-income beneficiaries sign on with MA because fee-for-service Medicare doesn't cover what they need, and supplemental benefits may cost more than the MA plan to secure. Gilfillan said that in the absence of eliminating MA, seniors should have access to a traditional Medicare option that serves as a benchmark and is more inclusive than fee-for-service is today.

If the feds took action to curb overpayments to MA insurers, that funding could back enhanced benefits for people in the traditional program, he said.

"We're saying, give them the right coverage upfront, right from the get-go," he said.

He also took MA plans to task for their focus on profitability. The largest national players in MA—UnitedHealthcare and Humana—are both for-profit players.

"MA today is not value-based care, it's value-destroying," Gilfillan said, "because it destroys the value of what we have in our healthcare dollar, taking dollars out for profits, corporate stock buybacks and dividends. That's not value-based care."

Jain did push back on this, as SCAN is one example of many in the space who are not-for-profit and are approaching the program through that lens, collaborating more closely with providers.

Gilfillan said that while he'd love to see these companies thrive, being not-for-profit does make it harder for them to keep up with the far larger, for-profit firms.

"We need to give those people a context to operate in, where they can optimize on the dimensions that are most valuable, most important to them," he said, "not trying to keep up with the [UnitedHealthcares], Aetnas, Cignas and Anthems."

What they could agree on: MA has been allowed to flourish because traditional Medicare has not been able to keep up with the evolving needs of seniors. Jain argued that fact is what makes augmenting MA, rather then eliminating it entirely, make the most sense.

"I think we're comparing a really bad thing to a slightly better thing," he said. "This is supposed to be at some level a program to give people security in their most vulnerable years. And I don't think fee-for-service Medicare does that.

"I just want to make sure we're not losing sight of the fact that this is a program that disproportionately enrolls poor beneficiaries. And right now, they don't have the alternative that you're talking about, these pie in the sky policy proposals that you're presenting."