10 Ways MedPAC Commissioners Think Regulators Should Fix Medicare Advantage Plans

— Improvements needed in network accuracy and transparency regarding denial rates, they say

 A photo of an Americare Medicare Advantage plan truck parked in Brooklyn, NY.

Medicare Payment Advisory Commission (MedPAC) members wrestled last week with how to prevent a range of frustrations they say providers and patients are encountering with Medicare Advantage (MA) plans.

Although the commissioners were just discussing ideas and didn't make any formal recommendations, MedPAC staff will analyze the commissioners' remarks for possible inclusion in an upcoming report to Congress -- a report that will suggest regulatory changes to help the plans work better for patients and providers.

This year, the number of Medicare beneficiaries enrolled in MA plans 50% of 65.7 million eligible, and as MedPAC chair and Harvard health policy professor Michael Chernew, PhD, noted, the program is only going to get "bigger and bigger."

These meetings give commissioners "a broad range of freedom to say whatever they want, and make a number of suggestions about problems and solutions," Chernew told Medpage Today in a phone interview.

But getting to an actual recommendation requires lengthy and complex staff analyses to understand possible unintended consequences, he said. Implementation may take years, and will only come after approval by the Centers for Medicare & Medicaid Services (CMS).

That said, here are some of the problems commissioners want the agency to address:

1. Pave a way for unhappy MA enrollees with "reasonable buyer's remorse" to leave their MA plans and have a "special election period" to buy a supplemental plan that picks up traditional Medicare's 20% Part B co-pays and hospitalization deductibles.

Beneficiaries have limited periods in which they can buy a supplemental plan without medical underwriting. Those periods are generally limited to their first 6 months of eligibility or, if they leave traditional Medicare later for an MA plan, they have a one-time 12-month period in which they can go back to traditional Medicare and get their supplemental plan back if it is still available.

"I'm in a state that does not have guaranteed issue rights to supplement outside of very restricted periods," said Gina Upchurch, RPh, MPH, founder and executive director of Senior PharmAssist, a nonprofit in Durham, North Carolina. "We see a lot of people that really cannot make the selection to go back" to traditional Medicare with a supplement plan because they would have to undergo medical underwriting, she said.

"If a member attests to a reasonable buyer's remorse, they [should] have guaranteed issue to go back to traditional Medicare" with a supplemental plan. "That's ideal from a public policy [standpoint]," said Scott Sarran, MD, MBA, consultant and principal at Triple Aim Geriatrics.

"People need to understand if someone is in MA, and for whatever reason doesn't like the prior authorization or the networks ... You really don't know what's going to happen to you. So switching back [to traditional Medicare] would be important," said Larry Casalino, MD, former health policy chief at Weill Cornell Medical School's Department of Population Heath Sciences.

2. Require MA plans to maintain up-to-date directories of providers, including clinicians, that are not only in network, but available to see new patients. CMS should step up efforts to audit those listings, the commissioners said.

"Provider directories are a problem. It's sort of ridiculous to enroll in a plan and have the provider directory be out of date. It's unbelievable we are having this discussion in 2023," said Brian Miller, MD, MPH, an assistant professor of medicine at Johns Hopkins University.

Numerous CMS reports over the years have documented high rates of inaccuracies in those directories, with clinicians going off contract or not accepting new patients during the plan year. CMS could verify through claims data to determine "to what extent the listed providers in the directory are actually seeing patients for a plan," Casalino suggested.

"Having out-of-date directories is completely unacceptable when we think about the fact that people will pick plans based on the coverage of their providers," said Stacie Dusetzina, PhD, professor of health policy at Vanderbilt University Medical Center in Nashville.

3. Study Medicare's rules for assuring that MA plan enrollees can get in-network coverage for medically necessary care with out-of-network specialists when the plan has no appropriate in-network specialists that can meet the patients' needs. "Who monitors that, and do we see that a lot?" Upchurch asked.

4. Mandate that beneficiaries have a reliable way to compare plans in terms of prior authorization review and compliance with various rules, perhaps requiring that such information be displayed on the Medicare Plan Finder, said Sarran.

"It should be clear to a prospective member making a buying decision how Plan X compares to Plan Y and their percent of denials, percent of overturns, maybe any corrective actions that have been taken against the plan, [and] enforcement actions by CMS," he said.

5. Prohibit plans from restricting first-choice access to Part B cancer drugs that are listed in the National Cancer Center Network compendia, or requiring the patient to try other drugs first. "There should be no requirement for a 'step' to get to anything that's in that category," Sarran said.

6. Require that each plan disclose on the Medicare Plan Finder whether it allows enrollees to get care at comprehensive or National Cancer Institute-designated cancer centers in network -- or with discounted co-pays at out-of-network facilities -- and to specify which ones.

"Prior research has suggested that there are some problems with network coverage of any of those levels of more specialized care," Dusetzina said.

A patient who needs specialty cancer care but can't get it in network might pay full price for that care, or leave MA for traditional Medicare without a supplement, thus paying 20% of all cancer care costs, "which is unaffordable," Dusetzina said.

Rather than having plans specify which specialty providers they include, perhaps requiring them to "highlight exclusions from their network might be an interesting approach," said Sarran. "And you could require listed exclusions on [the Medicare] Plan Finder of cancer centers, of teaching hospitals, of major hospital systems with large market shares. Again, we want an informed consumer. Industry can't reasonably argue against an informed consumer making good, informed decisions, so how do we enable that?"

7. Revamp MA plan star ratings metrics to reflect the stability and consistency of a plan's provider network in a way that would include each plan's prior authorization denial rate, and indicate how much enrollees can rely on their providers staying in-network.

"You know, we figure out how to pay people. So it feels like we should be able to tie these things together in a way that makes it really clear who is available, who's accepting patients," Dusetzina said.

8. Find ways to make sure beneficiaries know what they are giving up when they enroll in an MA plan with respect to being constrained to narrow provider networks and accepting delays or denials of care because of prior authorization.

"Anything we do that helps people understand what they're giving up and what they're getting I think is an absolutely central principle," said Betty Rambur, PhD, RN, professor of nursing at the University of Rhode Island.

"It's important that Medicare beneficiaries know what their trade-offs are; those trade-offs are often not clear," Miller said.

9. Require that MA plans list behavioral health plans in their directories by provider name rather than just giving patients a company to call.

Patients often don't really want to go see a psychiatrist, but if a doctor recommends it, "you want them to see someone good that you know, and that they would be happy with," and get feedback from that visit, said Casalino. Currently, doctors sometimes just have an 800 number to give the patient and no idea who the patient would end up seeing.

"It would be hard to exaggerate the discontent of a physician who has to do that," he said.

10. Improve the user-friendliness of the appeals process for both enrollees and providers. "The more we make that an easy remedy, the more plans will back away from unnecessary denials on the front end," suggested Sarran.

Chernew stressed that MA plans were designed to reduce unnecessary care and use the savings from that to add other benefits and reduce premiums.

"But that doesn't mean there aren't situations in which care is denied that shouldn't be denied, or that the quality in the plan is worse than it would be in fee-for-service," he said. Getting the balance between getting to efficient delivery systems, "versus the potential for [MA plans] to be overly aggressive is a challenging thing for CMS."

Chernew also emphasized that everyone agrees beneficiaries need to be better informed about the things they give up by choosing MA over fee-for-service, but given the complexities of the plans, "that is a daunting task."

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    Cheryl Clark has been a medical & science journalist for more than three decades.