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Is Medicare Advantage a Failed Experiment? Experts Debate

MedCity News / By Marissa Plescia

More than half of Medicare beneficiaries are enrolled in Medicare Advantage (MA), and enrollment in MA has steadily grown over the years. But as the MA program draws scrutiny from the federal government, should it stick around? Two experts disagreed on this topic during a panel discussion held Monday at HLTH 2023 in Las Vegas.

Dr. Rick Gilfillan, an independent consultant, called the MA program a “failed experiment.” Gilfillan is the former CEO of Trinity Health System and former director of the Center for Medicare and Medicaid Innovation (CMMI). He referred to the program as Subsidized Medicare Advantage because it’s “subsidized to the tune of between 25% and 32% a year in excess payments from CMS.”

“I say failed because for 35 years of its existence, privatized Medicare, now Subsidized Medicare Advantage, has cost more than traditional Medicare,” he said. “In 2023, those numbers are projected to be more than $75 billion to $120 billion in excess payments to MA over what the cost would be in traditional. From a quality standpoint, … what we can say is that [MA plans] put in place obstacles to care, made access to care more difficult.”

Meanwhile, Dr. Sachin Jain, CEO of MA insurer SCAN Health Plan, disagreed that MA is a failed experiment. He noted that Gilfillan was his first mentor in managed care and that the two worked together at CMMI. And while Jain said he agrees with Gilfillan on “most things,” he thinks Gilfillan is “dead wrong” when it comes to Medicare Advantage.

“You have to think about what we’re comparing Medicare Advantage to, which is fee-for-service Medicare, which was a program that for many years provided people with a sense of stability and security. As healthcare costs grew, as more cost shifting happened to traditional beneficiaries in the fee-for-service Medicare program, they felt less and less secure. … It’s debatable whether [MA] costs more or less, but let’s accept for a second Rick’s premise that it actually costs more. It may cost more because it does more. If you’re a beneficiary in the traditional fee-for-service Medicare program, CMS would have you believe that you don’t have teeth, eyes or ears because there’s no vision coverage, audiology coverage or dental coverage.”

However, Jain conceded that MA needs “refinement, reform, major tweaks and minor tweaks.”

Gilfillan acknowledged that traditional Medicare needs reform as well.

“I think we need to change Medicare, and I think we need to change MA,” he said. “I personally would do away with MA, I think it’s been too long, but that’s unrealistic. So what I would say is, let’s have a level playing field. Let’s create a level playing field where there’s a standard traditional Medicare benefit that includes an out-of-pocket cap, some vision, dental, hearing. And let’s compare it and let’s have a standard package in MA. Let’s stop the overpaying. The dollars we take out of MA will fund the extra benefits for both parties.”

He added that MA is not creating value for patients.

“MA today is not value-based care, it’s value-destroying care. Because it destroys the value of what we have in our healthcare dollar, taking dollars out for profits, for stock buybacks and dividends,” Gilfillan said.

Jain countered that SCAN Health Plan is a nonprofit health plan, and there are several other nonprofit health plans across the country that aren’t “feeding shareholders” and are working collaboratively with the provider community. While Gilfillan said he loves these types of companies, he’s not sure if they can beat the for-profit players like UnitedHealthcare, Aetna, Cigna and Elevance.

Ultimately, Jain believes that MA can be fixed, but healthcare professionals need to be the ones to step up.

“I do think there is an element of trying to recognize the flaws in the system, trying to fix them one-by-one,” he said. “I think we’ve been waiting for Congress to fix the overall system of care for 50 years. They’re not doing a better job today than they did 50 years ago. I think it’s up to us right now to look at these programs and try to make them better.”

OIG Updates the List of Excluded Individuals and Entities

The Health Group

OIG maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (“LEIE”). Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (“CMP”). To avoid CMP liability, health care entities should routinely check the list to ensure that new hires and current employees are not on it. The list should also be reviewed to ensure that vendors are not included on the list. We recommend all healthcare providers review employees and vendors against the list at the beginning of the year. The list is available here.

What Are Major Payers Offering Medicare Advantage Members in 2024?

Health Payer Intelligence / By Victoria Bailey

- As Medicare’s open enrollment period approaches, payers have announced new Medicare Advantage plan offerings for 2024.

Because Medicare Advantage plans receive flexibility to cover benefits beyond the traditional Medicare offerings, plans have an opportunity to differentiate themselves from their competitors with new benefits. In their 2024 offerings, major payers prioritized $0 monthly premiums, low-cost prescription drug coverage, and benefits addressing social determinants of health.

UnitedHealthcare, Humana, Cigna, and Aetna represent 18.3 million members and 60 percent of the Medicare Advantage market, according to estimates from KFF. Their new benefits provide insight into what payers are prioritizing in senior healthcare and their growing footprints can affect the Medicare Advantage payer landscape and consumers’ plan options.

UnitedHealthcare

UnitedHealthcare is expanding its coverage area to reach 96 percent of all Medicare beneficiaries.

The payer currently offers an online hub members can use to access their benefits and manage their appointments. The UCard is integrated with UnitedHealthcare’s member website and mobile app. Members can use the UCard to check in at an in-network provider’s office or pharmacy and can spend rewards in-store or online.

In 2024, the payer will introduce new benefits that make it easier for members to shop with their UCard. A mobile product scanner will allow members to confirm benefit eligibility for covered products when shopping in-store. A mobile UCard will allow merchants to scan a barcode for payment when a member is ready to check out.

The payer has also expanded its reach to an additional 700,000 people eligible for Medicare Advantage plans in 110 new counties and 2.7 million additional people eligible for UnitedHealthcare’s chronic special needs plans.
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Like many Medicare Advantage plans, UnitedHealthcare will continue offering dental, hearing, and vision coverage. In addition to having the largest Medicare Advantage network for medical providers, the payer boasts the largest national dental network, one of the largest national vision and hearing provider and retail networks, and one of the largest pharmacy networks.

In 2024, members will have stable or lower maximum out-of-pocket costs compared to 2023, according to the payer. In addition, standard Medicare Advantage plans will offer $0 copays for virtual visits, mammograms and colonoscopies, and routine dental, vision, and hearing exams…

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Celebrate National Physical Therapy Month

It's National Physical Therapy Month and I am pleased to share with you that APTA has worked with producers of the Viewpoint public television series to create a documentary-style feature and advertisement on the profession, organization, and ways physical therapy helps people stay healthy, active, and mobile.

The 60-second advertisement will air nationally tonight on Fox Business during primetime at 10:55pm ET (note that the airing could occur anytime within an hour of the scheduled time, depending on the news schedule). We encourage you to join us in watching for it tonight! The ad will air again on Oct. 8 on Fox Business, and then four times in each of the top 100 U.S markets, such as Boston, Houston, Chicago, Denver, and Phoenix for 400 airings throughout the month of October.

The documentary feature will air on public television as a part of the Viewpoint series throughout the month. You also can view APTA's full Viewpoint documentary anytime.

Lastly, we are running a ChoosePT consumer ad on a billboard in Times Square focusing on "The Economic Value of Physical Therapy in the United States" report throughout the month. View web cam footage of APTA's ad appearing in Times Square.

Thank you for your membership. We hope you have a wonderful National Physical Therapy Month, and we encourage you to share your celebrations with us! Use #PTmonth and #ChoosePT in your social media posts throughout October.

Sincerely,

Aaron Bishop

APTA Vice President Public Affairs

'Boarding' Patients for Days, Weeks in Crowded ERs is Common Now

Medical Xpress / By Denise Mann

When Hannah, a California marketing professional, showed up at her local emergency room in March 2023 for a pregnancy-related complication, she wasn't prepared for what happened next.

"I arrived at 2 p.m. and finally saw the obstetrics team at midnight," she recalled.

After an exam, doctors scheduled her for a procedure on the following day, but there wasn't a room available. "I ended up spending the night in a makeshift room in the lobby of the emergency room with a plastic sheet separating me from the rest of the people waiting for attention," Hannah said.

Unfortunately, this is not rare in U.S. emergency departments. Millions of people a day go to emergency rooms to seek care, but many, like Hannah, end up in a holding pattern due to overcrowding.

This is known as boarding, and experts say the problem is only getting worse.

"We are facing a national public health crisis," Dr. Aisha Terry, associate professor of emergency medicine at George Washington University School of Medicine and Health Sciences in Washington, D.C., and ACEP's president-elect, said Tuesday.

Speaking at an ACEP press briefing, Terry said that "emergency departments are overflowing, emergency physicians are overwhelmed, and patient care is at risk."

Research consistently shows that boarding leads to worse outcomes, medical errors, privacy issues and in some cases, death, she said.

Some people spend weeks, even months, waiting to get a room in the hospital or be transferred to an outside facility.

"It's jaw-dropping when you think about the length of time that people are waiting in the emergency department since there is no space to care for them," Terry said.

Boarding has been an issue for decades, but stresses owing to the COVID-19 pandemic such as staffing shortages and an uptick in mental health conditions have made it much worse.

In a new ACEP poll of 2,164 U.S. adults, 44% of respondents said they or a loved one experienced long waits in emergency departments, with 16% waiting 13 or more hours before being admitted or transferred. Almost half of adults surveyed said they would delay emergency care if they knew they could face boarding.

In all, 42% said hospitals should be primarily responsible for improving the situation, while 17% said Congress should pass legislation addressing boarding. Sixteen percent said insurers should ease cumbersome prior-authorization policies that can result in days-long waits for transfer to a skilled nursing facility.

Nine in 10 respondents consider emergency medical services (EMS) essential, roughly the same percentage who said additional or supplemental government funding for essential services should be a priority.

The poll has a margin of error of plus or minus two percentage points.

One health care worker quoted in the ACEP's presentation to journalists said, "Last week our 22-bed emergency department had 35 boarders and an additional 20 patients in the waiting room. Longest boarding time this month was over 200 hours with averages around 70 hours per patient. In addition, we have patients who unfortunately have died in our waiting room while awaiting treatment. These deaths were entirely due to boarding."

Terry told reporters that resource and staff shortages can't be accepted as the new normal.

"We need action now to preserve the safety net for the lives we work every day to save," she said.

ACEP has suggested creating a regional dashboard of available beds that emergency departments can use when needing to place someone. In addition, reimbursement incentives for hospitals that transfer people to avoid extreme boarding could also make a difference, the group suggests.

Terry added that tuition reimbursement, stress relief programs and suicide prevention services need to be available for health care workers to help address the staff shortages. Laura Wooster, senior vice president of advocacy and external affairs at ACEP, agreed.

She added that some groups such as kids in mental health crises are disproportionately affected by staffing shortages and emergency room boarding situations.

Addressing the crisis starts with efforts to increase the number of beds available for these kids in the community, Wooster said. Mental health mobile crisis teams can also help reach these kids where they are, she added.

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