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Analysis by Tim Rowan, Editor Emeritus


erennial Home Health enemy MedPAC angered a different group last week by releasing a status report on insurance companies participating in the Medicare Advantage program.1


The report details the way in which giant, for-profit, health insurance companies improperly increase per-customer payments by upcoding their health assessment at enrollment, and then slash costs by denying coverage for healthcare services that traditional Medicare would have honored. MedPAC was also critical of the practice of requiring prior authorizations, backed up by utilization review algorithms that are supposedly intended to “minimize furnishing unnecessary services” but which effectively increase denials for necessary care.

According to the report, MedPAC expects CMS to pay MA plans $88 billion in 2024. 

On January 12, a meeting to discuss the report ended in what one reporter politely described as “a kerfuffle.” Other witnesses to the meeting chose to describe it as a shouting match.

“One member, Brian Miller, MD, MPH, of Johns Hopkins University in Baltimore, accused panel leadership of issuing a negative status report on MA plans’ market dominance, saying it had been ‘hijacked for partisan political aims to justify a rate cut to Medicare Advantage plans.’

“Miller said the analysis … ‘appears to be slanted to arrive at a foregone conclusion in order to set up and provide political cover’ just before the Centers for Medicare & Medicaid Services prepares its annual rate notice for MA plans, expected in coming weeks. ‘The chapter reads like attack journalism as opposed to balanced and thoughtful policy research.'”2

Report authors fired back, citing numerous ways MA plans generate higher revenue, including enrolling people who are relatively healthy, known as favorable selection. They then vigorously scan patients’ medical histories and charts to code for health factors that generate higher per-capita payments, known as coding intensity, often spending less on services. Coding intensity is also the difference between a risk score that a beneficiary would receive in an MA plan versus in fee-for-service. Though MA plans skew toward healthier enrollees, MedPAC found that MA risk scores are about 20.1% higher than scores would be for the same beneficiaries had they enrolled in Fee For Service Medicare.


Namath, Walker, Shatner and Brokers

Criticism of MA plan behavior did not only come from MedPAC commissioners and report authors. For example, Lynn Barr, MPH, founder of Caravan Health, which was acquired by CVS Health through its acquisition of Signify Health, exposed what the annual TV ads do not make clear, that their 800 numbers go to brokers, not to any one plan.

“This is not the big, lovely, glowing success that everybody says it is. And we continue to create policies that drive people into these plans. Medicare allows money paid to MA plans to be used for broker commissions as high as “$600 to recruit them, plus $300 a year every year that they stay in the MA plan.

“We have allowed MA to buy the market, and that is why MA is growing. It’s not because the quality’s so great. People don’t love the prior auth, people are leaving their plans a lot. Aside from Medicaid, Medicare is the least profitable payer for doctors. And at the same time, we give all this money to the plans. It’s unconscionable.”

Adding to the “kerfuffle” with a powerful anecdote, Stacie Dusetzina, PhD, of Vanderbilt University Medical Center in Nashville, Tennessee, noted that even cancer patients often have trouble getting necessary care because of the plans’ limited networks. She referenced a January 7 NPR story3 about an MA enrollee who could not get the cancer care he needed from his MA plan, and could not get out of the plan without facing 20% in expensive copays. In all but four states, supplemental plans that could pick up the difference can reject patients with costly conditions.

“When you are 65 and aging into the program,” Dr. Dusetzina summarized, “you are healthy at that time and may not be thinking about your long-term needs. [If you did], it would push you to think harder about the specialty networks that you may or may not have access to when the MA plan is making your healthcare decisions.”


1 A 30-page slide presentation is available to the public at medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-status-report-Jan-2024.pdf. The complete report is available only to MedPAC commissioners. The charts on slides 26 and 27 show how MA plans learned to pad profits in 2018 and increased the practices exponentially since then.

2 Cheryl Clark, MedPage Today January 16, 2024 medpagetoday.com/special-reports/features/108275

3 npr.org/2024/01/07/1223353604/older-americans-say-they-feel-trapped-in-medicare-advantage-plans


Tim Rowan


Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. RowanResources.comTim@RowanResources.com



©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com