Correcting the Record: The Facts on Medicare Advantage Payment and Accountability

The Wall Street Journal recently published a story regarding diagnoses and plan payments in Medicare Advantage. The story was fundamentally flawed and overlooked the value of Medicare Advantage for millions of American seniors.

Here are the facts:

• More than 33 million seniors choose Medicare Advantage because the program provides better health outcomes at a lower cost for beneficiaries than Fee-For-Service Medicare.
• Medicare Advantage consistently outperforms Fee-For-Service Medicare in efficient use of taxpayer dollars, ensuring more resources can go toward keeping seniors healthier.
• Health risk assessments in Medicare Advantage help keep seniors healthier and more independent by identifying gaps in care and collecting critical information that allows health care providers to create personalized care plans, tailor interventions, and monitor health changes over time.
• All diagnosis codes submitted under the Medicare Advantage program must meet the same rigorous standards, whether they originate in a doctor’s office or with an in-home health risk assessment.
• Medicare Advantage diagnoses are assessed for accuracy through the Risk Adjustment Data Validation audit process. Fee-For-Service Medicare consistently records higher payment error rates than Medicare Advantage, according to CMS.
• Recent risk-adjustment changes in Medicare Advantage dramatically reduced the number of diagnoses that qualify for higher government payments, including diagnoses cited in the Journal’s report.

Policymakers designed Medicare Advantage to provide a fuller picture of seniors’ health status than Fee-For-Service Medicare, ensuring care would be better coordinated and more effective — one of several fundamental facts ignored in the Journal’s reporting. Better Medicare Alliance supports solutions to increase payment accuracy in Medicare Advantage, including best practices around health risk assessments to ensure consistent quality and encourage provider follow-up where appropriate.

To strengthen in-home HRAs, policymakers should expand and codify in-home HRA best practices. Best practices include:

• All components of the annual wellness visit, including a health risk assessment such as the model health risk assessment developed by the Centers for Disease Control and Prevention (CDC)
• Medication review and reconciliation
• Scheduling appointments with appropriate providers and making referrals and/or connections for the beneficiary to appropriate community resources
• Conducting an environmental scan of the beneficiary’s home for safety risks, and need for adaptive equipment
• A process to verify that needed follow-up care is provided
• A process to verify that information obtained during the assessment is provided to the appropriate health plan provider(s)
• Provision to the beneficiary of a summary of the information, including diagnoses, medications, scheduled follow-up appointments, plan for care coordination, and contact information for appropriate community resources
• Enrollment of assessed beneficiaries into the health plan’s disease management/case management programs, as appropriate

To ensure transparency and accountability for in-home HRA best practices, CMS should mandate annual reporting from health plans that could include the following metrics:

• The organization’s in-home HRAs are compliant with CMS guidelines, including the specified components of the HRA (e.g., contain questions on housing, transportation, and food)
• Key metrics, including the number of:
  • In-home HRAs conducted
  • Medication reviews conducted
  • Appointments scheduled as a result of an in-home HRA
  • In-home HRA reports delivered to beneficiary’s primary care provider (PCP) or conducted by the beneficiary’s PCP
  • Beneficiaries receiving an in-home HRA that are enrolled in disease or case management programs

For an in-depth look how Medicare Advantage payments work, and how the program stays accountable to patients and the government, read more here.