Taven­ner slams CMS over Medi­care Ad­van­tage un­der­pay­ments

Modern Healthcare - - LATE NEWS - —Vir­gil Dickson

The CMS’ previous ad­min­is­tra­tor, Mar­i­lyn Taven­ner, crit­i­cized the agency af­ter an anal­y­sis showed it has un­der­paid Medi­care Ad­van­tage plans for the costs of treat­ing in­di­vid­u­als with chronic con­di­tions.

Key find­ings from a study of fed­eral data by Avalere Health, funded by America’s Health In­sur­ance Plans, found that the risk-ad­just­ment model used by the CMS low­balls the cost of treat­ing chronic pain by $14.3 bil­lion, os­teoarthri­tis by $13.4 bil­lion, de­pres­sion by $8.9 bil­lion and rheuma­toid arthri­tis by $5.3 bil­lion.

“Rather than re­ly­ing on an an­ti­quated fee-for-ser­vice ap­proach as the model for care de­liv­ery, the CMS should fo­cus on strength­en­ing Medi­care Ad­van­tage and the in­no­va­tive pro­grams that im­prove se­niors’ health,” Taven­ner, now CEO of AHIP, said in a state­ment. (See Q&A with Taven­ner, p. 30.)

This is the first time Taven­ner has pub­licly crit­i­cized her former agency, and it comes as AHIP faces scru­tiny over los­ing two of its big­gest mem­bers, Aetna and United Health Group.

The two in­sur­ers are found­ing mem­bers of Wash­ing­ton’s new­est health in­sur­ance lob­by­ing group, the Bet­ter Medi­care Al­liance, which fo­cuses on Medi­care Ad­van­tage. They and their in­sur­ance busi­ness col­leagues have made it a pri­or­ity to strengthen the in­creas­ingly prof­itable Medi­care Ad­van­tage pro­gram by keep­ing pay­ment rates sta­ble.

The Avalere study comes months af­ter the CMS ad­mit­ted it un­der­paid health plans that en­roll large num­bers of ben­e­fi­cia­ries du­ally el­i­gi­ble for Medi­care and Med­i­caid. It has an­nounced plans to ad­just its risk model to ad­dress the is­sue. The CMS uses a prospec­tive model that mea­sures health sta­tus in a base year to pre­dict costs for the fol­low­ing year. Crit­ics say some in­sur­ers have bilked the sys­tem by ex­ag­ger­at­ing the con­di­tion of their Medi­care Ad­van­tage pa­tients to get higher risk-ad­just­ment pay­ments.

AHIP said Medi­care Ad­van­tage plans have pro­vided “tai­lored care co­or­di­na­tion and dis­ease man­age­ment pro­grams that al­low ben­e­fi­cia­ries to bet­ter man­age their chronic con­di­tions.”

The in­sur­ance lob­by­ing group pointed to re­search that shows the pro­gram im­proves health out­comes. It also said Medi­care Ad­van­tage ben­e­fi­cia­ries con­sis­tently report high sat­is­fac­tion with the pro­gram.

“While the CMS is con­sid­er­ing changes to the risk model to ad­dress un­der­pay­ments for low-in­come ben­e­fi­cia­ries, the agency may also want to con­duct re­search on meth­ods to ad­dress un­der­pay­ments for in­di­vid­u­als with chronic con­di­tions,” said Tom Korn­field, vice pres­i­dent at Avalere.

A CMS spokesper­son did not im­me­di­ately re­turn a re­quest for com­ment.

This is the first time Taven­ner has

pub­licly crit­i­cized her former agency.

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