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.
 ..
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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Census Bureau: ‘Aging-Ready Homes’ May be in Short Supply 

McKnight’s Home Care / By Adam Healy
 
As the older population of the United States continues to grow, the Census Bureau fears that the stock of what it calls “aging-ready homes” may be inadequate to keep up with demand.
Aging-ready homes are defined by three features: A step-free entryway, and a bedroom and bathroom on the entry level, according to the bureau in its new report. Informed by the 2019 American Housing Survey, estimates place the number of aging-ready homes in the U.S. at about 50 million households, or only 40% of all homes in the country.
 
Many older households — where at least one resident is 65 years or older — do not have the accessibility features to support aging in place. Around 4 million of these older households, or 11% of older households in the U.S., reported challenges related to living in their home. For households where a resident is 85 years or older, about 25% reported home-related living challenges.
 
The most frequently reported difficulty among older households was trouble entering the home. Though step-free entryways can help, this feature may not be available for many. Of the 124 million housing units included in the report, nearly half had steps leading to the entryway. This challenge can be more pronounced for residents of certain geographic areas. For example, only 1 in 5 houses in New England have step-free entryways, and many of these homes are multistory. Multistory homes are less likely to have both a bathroom and a bedroom on the entry level, according to the report.
 
Home accessibility challenges also disproportionately affect people of lower income levels. These individuals generally experienced more accessibility issues within their homes compared to those earning greater incomes.
 
Despite the importance of home accessibility features for aging in place, very few people reported plans to make modifications to support aging. Only about 6% of older households reported plans to make accessibility improvements to their homes. The Census Bureau report noted two possible reasons for this: First, home improvements are costly and may be unaffordable for low-income households; building an entry floor bathroom can cost anywhere between $6,000 and $90,000, according to the report. Second, people who rent rather than own their homes may have a lack of control over home modifications for accessibility.
 
A Harvard study released in March found that older homeowners spent more than $84 billion in projects to facilitate aging in place. Some organizations, such as the U.S. Department of Housing and Urban Development or Habitat for Humanity, provide financial aid for older adults looking to make such accessibility modifications to their homes.