Senate Finance Targets Medicare Advantage Brokers

Stat News / By John Wilkerson
 
Senate Finance Committee members from both parties took aim Wednesday at insurance brokers that sell plans for large Medicare Advantage insurers.
 
Older adults at times have more than 100 plan options, and brokers help them choose the right one. But brokers can be incentivized by large insurance companies to aggressively sell plans that are a poor fit for the Medicare beneficiaries they’re supposed to help. Brokers also sometimes collect private information that they sell to multiple insurance companies. Those brokers tend to have a national scope, just like the large insurers they represent, compared to the independent, local brokers.
 
“They are big private marketing companies in the middle between seniors and their coverage,” Chairman Ron Wyden (D-Ore.) said.
 
There were two main goals of the hearing: to protect seniors and disabled beneficiaries from unscrupulous marketing tactics, and to give small insurance companies a level playing field to compete with large, national insurers.
 
Wyden released a report a year ago that highlighted the aggressive marketing practices that brokers sometimes use, and he said he plans to investigate more.
 
At the heart of the problem is the large amount of money that big insurers pay brokers for 
enrolling seniors in their plans, according to Krista Hoglund, CEO of Security Health Plan in Wisconsin. Medicare places a $611 cap on the commission that brokers can earn from enrolling a beneficiary into a Medicare Advantage plan, but large insurers often pay additional fees to brokers that can add up to more than $1,300.
 
To sell those plans, brokers flood seniors with phone calls and marketing materials that misrepresent the value of those plans. One tactic, which Wyden called “ghost networks,” involves promising older adults access to providers who aren’t taking new beneficiaries. Brokers will even sometimes switch seniors from one plan to the next without the beneficiary’s knowledge, Hoglund said.
 
Hoglund recommended making insurers and brokers disclose how much brokers are paid to sell plans. Once Medicare has that information, it should standardize and limit broker compensation.

Read Full Article

What Home Health Providers Are Learning From HHVBP’s First Full Year

Home Health Care News / By Patrick Filbin
 
In the midst of the first full performance year for the expanded Home Health Value-Based Purchasing (HHVBP) model, providers are figuring out where they are succeeding and where there is room for improvement.
 
HHVBP continues to save hundreds of millions of dollars each year, according to the U.S. Centers for Medicare & Medicaid Services (CMS).
 
And the initial set of HHVBP scores — on the provider side — is influencing the operations of home health providers of all sizes.
 
“We are steering the entire company towards value outcomes,” Ananth Mohan, COO of Elara Caring, told Home Health Care News. “It adds to the complexity of how we do business, so you have to be sophisticated about it. With the midway point scores, it’s really geared us up and reaffirms that this is the way the world’s going to go.”
 
HHVBP scores
 
The HHVBP model, which CMS expanded from nine demonstration states to home health agencies across the country on Jan. 1, 2023, was implemented to incentivize home health agencies to improve the quality of care they provide to Medicare beneficiaries.
 
The goal of the model is to link Medicare reimbursement to the quality of care, rather than just the quantity or volume of services.
 
The way CMS does that is through quality measures and performance scoring. Those measures include patient outcomes, patient experience, process measures and timely initiation of care.
 
Each category has specific measures that contribute to the overall performance score. The performance period usually lasts a year. During that time, CMS evaluates the data that providers share, and, from that, a score is returned to providers that can negatively or positively affect their reimbursement.
 
After reviewing the scores Elara Caring received at the six-month point, Mohan is pleased with the early results. In particular, Mohan is encouraged in how the results have affected day-to-day operations.
 
“On the hospitalization front, the results made us think about being more programmatic,” he said. “It changed how we think about centers of excellence around certain diseases, how we think about which areas of the company where we’re more hospital-heavy. It’s also changed the way we think about things like remote patient monitoring. RPM is not incentivized today, so you’re essentially giving it away. But if you’re giving it away in this mode,l then it matters, because it drives outcomes.”
 
The Dallas-based Elara Caring is one of the largest home health, home care and hospice providers in the country, with about 200 locations across 17 states.
 
The HHVBP model has given Elara Caring insights into what is working and what isn’t working at different locations.
 
For instance, the midpoint check-in has reinforced the need for predictive tools.
 
“Otherwise, we’re always just looking backward,” Mohan said. “So, we built an in-house, custom predictive tool that our branches are able to use and see on a real-time basis what they’re good at and what they need to improve on. I continue to be impressed at how this resonates culturally with people. If you give them the right tools, they can make an impact. We’re seeing that.”
 
On the flip side, the early results have shown that reducing hospitalizations will be a “never-ending challenge.”
 
For patient satisfaction and OASIS scores, the simplified strategy is to see where improvements need to be made and to stay on top of them. For clinically-driven results, it’s a tricker task.

Read Full Article

The Economic Value of Physical Therapy in the United States

Read the Report

APTA's landmark report goes beyond a simple comparison of treatment costs to show how physical therapist services are more cost-effective than other courses of care.

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.”