SCAN CEO Jain: Don't glorify fee-for-service to improve Medicare benefit

SCAN CEO Jain: Don’t glorify fee-for-service to improve Medicare benefit

When stakeholders consider ways to improve Medicare Advantage, they should be careful not to idealize paid Medicare in the process, warns SCAN Health Plan CEO Dr. Sachin Jain.

Medicare Advantage (MA) is a growing force in healthcare. More MA plans are emerging each year and the size of their beneficiary populations continues to grow. Although the program currently does not cover palliative care outside of the demonstration of the Value Based Insurance Design (VBID) model, it remains one of the few reimbursement pathways for palliative care and services to address the determinants social health.

MA has come under fire from lawmakers and regulators in recent months over the plans’ marketing practices and pre-clearance policies, as well as cost and quality issues.

While Jain acknowledged that problems within MA need to be addressed, he said effective solutions will not be as simple as re-embracing the fee-for-service paradigm.

“I am the first person to say that none of these [Medicare Advantage] entities are perfect,” Jain told Hospice News. “Let’s be a better industry. Let’s regulate this industry. But there’s a kind of glorification of paid health insurance that I think is misplaced because it doesn’t necessarily recognize some of the challenges beneficiaries face.

California-based SCAN Health Plan is a $4.3 billion Medicare Advantage (MA) organization that covers more than 270,000 members. The organization will begin participating in the VBID demo in 2023. Jain recently published some of his views on MA versus fee-for-service in his column in Forbes.

Through Medicare Advantage, the US Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies to provide coverage for Medicare beneficiaries. In 2023, the number of MA plans will increase to 3,998, up 6% from 2022.

In 2022, these plans covered more than 28 million Americans, or nearly half of the entire Medicare population, according to the Kaiser Health Foundation. Today is the last day of Medicare’s open enrollment period for 2023, but many expect MA plans to see further gains.

Concerns revolve around marketing, pre-clearance

As the rise in signup rates indicates, MA plans have been popular with consumers. Nearly 88% said they were satisfied with their coverage in a June survey by eHealth.

But recent reviews of the program have prompted calls for stricter oversight.

Last month, the Senate Finance Committee released a report indicating that third-party marketing companies used deceptive practices to enroll beneficiaries in MA plans. This included reports of some consumers being enrolled without having any contact with a health plan or receiving misleading information about coverage, out-of-pocket costs or provider networks.

This follows an investigation earlier this year by the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services that found that some plans’ prior authorization methodologies were leading to denials of care. medically necessary.

The same report also indicated that 18% of vendor payment requests that were denied by these MAOs also met CMS requirements, although the OIG acknowledged that most of these denials were due to human error during processing. claims processing. Some of the payment and pre-authorization denials were also reversed, often after a recipient or provider challenged the decision, OIG noted.

“I am by no means a fanatic of Medicare Advantage. All of these are important and serious considerations that we should weigh very carefully and also reflect some of the reality of what it is like to be a consumer over the age of 65, looking for a solution for their care. health,” Jain said. “At the same time, I think sometimes some of the conversations around Medicare Advantage are blind to some of Medicare’s fee-for-service flaws.”

Among these flaws are the higher costs to consumers compared to MA, according to Jain.

Reduced out-of-pocket costs, added benefits attract seniors to MA

Recent research conducted by ATI Advisory for the Better Medicare Alliance found that, typically, Medicare Advantage enrollees save about $2,000 per year in health care costs compared to traditional Medicare.

Medicare Advantage plans also have the option to provide additional benefits that traditional health insurance does not cover, including eyeglasses, hearing aids, preventative and comprehensive dental benefits, fitness benefits, and a range of home and community services.

Examples of these include community-based palliative care and programs addressing social determinants, such as meals, transportation, home modifications, and home support services, among others.

“There is a tendency to ignore the fact that there are so many things that are not covered by traditional health insurance, that are covered by NI. People have been very cautious about this, for not necessarily being negative about a program that people have really relied on for a long time,” Jain said. “But when you look at the details of what’s covered and what’s not, it’s pretty shocking how little older people are protected from a total cost perspective.”

Palliative care benefits are of particular interest to palliative care providers.

The number of plans offering palliative care at home will increase to 157 next year from 147 in 2022, according to an analysis by ATI Advisory. This does not include plans that offer palliative care through separate programs like Special Supplementary Chronic Illness Benefits (SSBCI) or VBID Demonstration, and the details of these benefits and what they include may vary by different health plans.

While some stakeholders have argued that existing palliative care benefits are not sufficient to meet the growing needs of patients, for now, providers have few other options for obtaining reimbursement.

Outside of PA, providers can seek reimbursement through ACO relationships or paid health insurance, which only covers physician or nurse practitioner services. Today, a significant number of palliative care programs are still supported primarily by philanthropic donations.

MA plans under increased scrutiny

Tighter oversight of PA plans will likely remain on the federal government’s agenda for 2023.

CMS has already informed MAOs that it will improve its reviews of marketing materials before they reach consumers, and today the agency proposed rules to implement an electronic pre-clearance process and establish related interoperability requirements. If made final, it would promote faster clearances, the agency said.

The OIG and the Senate Finance Committee have asked CMS to reinstate the MA plan requirements that were reversed under the Trump administration. This includes certain rules related to marketing and advertising.

The finance committee also called for “best practice” requirements for agents and brokers, better tracking of MA opt-out models, better sources of information for beneficiaries and, again, stricter marketing rules.

Congress is also considering a series of bills aimed at Medicare Advantage, including one introduced last week regarding mental health coverage.

Other bills include the Medicare & You Handbook Improvement Act, introduced last month by Sens. Maggie Hassan (DN.H.) and Dr. Roger Marshall (R-Kans.), To improve the information consumers receive when making enrollment decisions. In October, Representatives Mark Pocan (D-Wisc.) and Ro Khanna (D-California) also introduced a bill that would ban MA plans from using the name “Medicare” in their titles or advertisements.

In September, the House passed the Improving Seniors’ Timely Access to Care Act, which would implement measures to streamline the pre-approval process. The Senate is currently reviewing the bill.

Jain told Hospice News that the MA program could benefit from an improved risk adjustment model with better coding, as well as better documentation and coordination of care delivery.

“We should have a so-called Medicare Advantage ‘never happen’ set. We should never afford to allow waits and delays in people’s care,” Jain said. , people have care coordination issues all the time Medicare Advantage plans say they’re better, but we need to demonstrate that we’re better And, I would say, have a set of metrics that actually look at key events of people’s lives and ensure that we meet what people need at these events.

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