With an ever-increasing number of Medicare Advantage plans, older adults have begun considering their options for Medicare coverage—to stay with traditional Medicare or to opt to enroll in something new. Medicare Advantage plans are offered by private companies that contract with Medicare to provide services typically covered by Medicare Parts A, B, and D to their enrollees.
Brookdale Department researchers Claire Ankuda, MD, MPH, and Melissa Aldridge, PhD, MBA, and colleagues are calling for a closer examination of Medicare Advantage plans—a need that is becoming more urgent as these plans now cover nearly 50 percent of Medicare beneficiaries.
In an essay published in The New England Journal of Medicine, the researchers identified a number of issues with the current system, notably the lack of data on the quality of local health care services and the focus of this data on healthy individuals rather than on those with serious illness.
One result of the lack of data: It is not clear how well Medicare Advantage plans take care of older adults with serious illnesses, even as these plans enroll more and more of these patients, according to the researchers, which is likely not a surprise to clinicians on the frontlines of care but may be less apparent to health care policymakers, a key audience for this analysis.
“There’s an incredible diversity across Medicare Advantage, and we are not appropriately measuring quality to understand what plans are providing the best care for patients, especially those with serious illness such as cancer, advanced heart failure, and lung disease,” says first author Dr. Ankuda, Assistant Professor in the Brookdale Department of Geriatrics and Palliative Medicine. “These are the patients who are trying to access hard-to-obtain costly treatments that can make a difference in the quality of life and how long they live.”
For example, the researchers found that while there may be plenty of quality data for individual plans, these data are typically aggregated among patients living in different states and receiving care at multiple health systems, so there is not data available about how plans are performing on a “local” level, and, therefore, what type of performance an individual might expect. In addition, these plans rely on the Coordinated Assessment and Placement System (CAPS) surveys, which by design capture far fewer people with serious illness and focus instead on healthy individuals.
“We all know that insurance is great until you actually have to use it,” Dr. Ankuda says. “Many of us have had the experience of not understanding our benefits until we are sick, and then realizing it can be a struggle to get the care you need.”
Also, the researchers say that while Medicare Advantage has been growing in popularity among all populations, enrollment is rising disproportionately among Black and Latinx people, so any deficiencies may result in racial and ethnic disparities in quality of care and outcomes.
At the time of publication, the researchers said Medicare Advantage enrolled 48 percent of Medicare beneficiaries, and that Medicare Advantage was expected to account for approximately 60 percent of beneficiaries by 2030. Medicare Advantage plans come in many types, but all are required to cover both Part A, hospital insurance, and Part B, medical insurance. However, they can, and do, create barriers to services through various restrictions.
The essay was published in the May 11, 2023, edition of the journal. The authors also include researchers at Weill Cornell Medical College; the Perelman School of Medicine, Philadelphia; Harvard Medical School; Brown University School of Public Health; Vanderbilt University and the Veterans Affairs Tennessee Valley Healthcare System; and the RAND Corporation.
Some highlights of the analysis:
For beneficiaries with serious illness, there aren’t sufficient data to evaluate quality of care. For three consecutive years, the Medicare Payment Advisory Commission (MedPAC) has stated that it cannot provide accurate descriptions of care quality. While some data have been released, they are both incomplete and unreliable. More needs to be done to cull meaningful data.
Information is lacking on supplemental benefits. Such benefits are of great importance to those with chronic illness who require nonmedical assistance in the form of meals, transportation, and caregiver benefits.
Additionally, the quality bonus program (QBP), which offers incentives for high-quality care, needs strengthening and accountability. Implemented a decade ago, the QBP continues to face questions about its accuracy in quality measurement. Says Dr. Ankuda, “I worry that the QBP is not capturing the voices of adults with serious illness. If the program is not hearing from these adults, or factoring in their experiences, the accuracy of its reporting has a true missing piece.”
The authors make a series of detailed recommendations, including:
Improve the quality and actionability of data to support transparency.
Improve quality measurement to support accountability (particularly within the QBP) and quality improvement.
Invest in critical review of the Medicare Advantage program.
The authors also outline several strategies for improvement:
Congress could commission a report from the National Academies of Sciences, Engineering, and Medicine on quality of care in Medicare Advantage.
The National Institutes of Health could prioritize research on care delivery.
The Medicare Compare website would benefit from clearer context. The Centers for Medicare & Medicaid Services, which runs the website, could and should publish encounter data, as well as require data on supplemental benefits, the researchers say.
In the end, evidence-based improvements could help specialists provide better care for older adults, especially those who may need more expensive care.
“The goal is to create an environment that incentivizes insurance plans that are providing the right care for the right patients, and we hope that is a system that would make it easier for physicians to provide care without serving as the middleman between the insurance company and the patient,” says Dr. Ankuda.