Medicare Advantage analysis sparks infighting at MedPAC meeting

A MedPAC meeting on the status of Medicare Advantage held Friday began with numbers on enrollment and insights into coding diagnoses before devolving into contentious debate over the quality of the report and whether the program is a good development for healthcare in the country.

Brian Miller
Brian Miller (LinkedIn)

Brian Miller, an assistant professor of medicine at John's Hopkins University, was at the center of complaints toward the status report compiled by policy analysts, arguing that the report only highlighted the negatives of the program and that past suggestions of his have not been taken into consideration.

Because Miller believed the report was decidedly anti-Medicare Advantage, he challenged the analysts to name three positive things about the program, calling into question the objectivity of the report. They responded that they strive for balance, and the commission, which is a nonpartisan independent agency that advises Congress on Medicare, has a long history of supporting private plans in the Medicare program. When chair Michael Chernew, professor of healthcare policy at Harvard, attempted to move along the conversation to the next commission member, Miller persisted.

"I think this is important for the public record because it gets to how balanced we are and how we approach programs, and this didn't really feel very balanced," he said. "There are plenty of bad things definitely that need to be improved ... I think it's really important again that it's a neutral thoughtful policy analysis."

Better Medicare Alliance, an advocacy organization in support of MA, stated they have "concerns" about MedPAC's methodology in the recent report. They highlight how 99% of patients have enhanced supplemental benefits in plans with $18 premiums.

"Relative to beneficiaries in fee-for-service Medicare, Medicare Advantage beneficiaries are lower-income, more diverse medically and socially complex and increasingly live in rural areas," said President and CEO Mary Beth Donahue in a statement shared with Fierce Healthcare following the hearing.

Over the course of the more than two-hour discussion, many members pushed back against the claims, praising the analysts' comprehensive look at Medicare Advantage in the report.

"I actually didn't read it that way," said Vanderbilt Health Policy Professor Stacie Dusetzina, referring to Miller's earlier comments and acknowledging there isn't a lot of data about Medicare Advantage compared to other programs. "Medicare Advantage seems to be really great for beneficiaries, but then when it's not great, it's really not great. It's often something that's hard to measure when it's not going well because it's a relatively small part of the population."

She explained that members who face prior authorization denials, or are at the whim of inadequate provider networks for high-cost services like cancer centers or are part of a small population that experiences a disproportionate amount pain caused by MA. Many patients do not consider which specialty networks they will have access to when they first sign up for MA plans. She suggested that the commission should consider how to highlight negative experiences and show those through quality of beneficiary assessments.

Miller later suggested the fee-for-service program have a quality oversight system similar to MA's star ratings program. He also voiced concern with chair Chernew.

"It's not lost on me that this discussion is coming immediately prior to the CMS Medicare Advantage rate notice, which we can expect to see in the coming days to weeks," he said. "The chair has noted he is in regular communication with CMS leadership. This gives the appearance — that MedPAC is an independent, thoughtful policy organization — is being hijacked for partisan political aims, while the organization's analysis appears to be slanted to arrive at a foregone conclusion, in order to set up political cover for a massive MA rate cut. I note the many intellectual inconsistencies in this document, which I have spent untold hours reviewing, that result in intellectual somersaults."

He said the report suggests overpayments have doubled under the Biden Administration.

"What conclusion should I reach: that CMS leadership is unable to oversee the MA market, or that the recent and appropriate RADV audits are totally ineffective? My sense is that both of those conclusions are wrong," Miller said, before listing a series of prior suggestions for data analysis and methodology practices he said the commission largely ignored.

Chernew said during the meeting that the report merely lays out the facts and doesn't draw conclusions, and acknowledged that MA is popular for beneficiaries because of a "lot of extra stuff" due to both efficiencies and federal payments.

Michael Chernew
Michael Chernew (Harvard Medical School)

In a comment submitted by commission member Gregory Poulsen, a senior vice president at Intermountain Healthcare, he said he's a "huge MA fan" but that not all MA plans add value or are equal. One study he cited said that MA plans owned by or integrated with providers outperform other MA plans on 70% of 114 metrics. The successful plans, he believes, are great at coding and risk adjustment documentation or at effectively managing care to reduce cost.

One slide presented by the analysts shows that coding and selection are causing MA payments to exceed spending that would have occurred in fee-for-service Medicare. In 2024, the disparity is projected to grow largest yet, to the tune of $88 billion above spending on fee-for-service.

MedPAC analysis also revealed that 52%, or 31.6 million people, of Medicare beneficiaries are enrolled in MA plans. It found that MA enrollment is concentrated in a few large firms, potentially limiting competition. As MedPAC has argued in the past, their report said the quality bonus program is costly and doesn't judge quality effectively. Payments to MA plans have increased every year since 2015, hitting its peak in 2023 at $12.8 billion, according to KFF.

The commission said MA plans have more financial incentive to code more diagnoses than its fee-for-service counterparts, leading to higher payments and more inequity across MA plans. From 2020 to 2022, chart reviews and health risk assessments made up nearly half of MA coding intensity. MedPAC recommends eliminating health risk assessments from risk adjustment to balance out inequity in the market.

"In my opinion, we have overpaid Medicare Advantage tremendously," said Caravan Health founder Lynn Barr during the meeting. "I believe this is what the data shows. We have allowed MA to buy the market. That is why MA is growing. It's not because the quality is so great. People don't love the prior authorizations, people are leaving their plans a lot. This is not the big, lovely success everyone says it is. We continue to create policy that drives people into these plans.

"I think we've got to do something to reduce these payments to MA," she added.

Updated: The story has been updated to correctly transcribe a quote from Brian Miller calling the RADV audits appropriate.