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A Review of Medicare Advantage Policy Through the Lens of Geriatrics and Palliative Care

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Abstract

Purpose of Review

Medicare Advantage (MA), or Medicare Part C, is the program that allows private health insurance companies to provide Medicare services. MA is growing exponentially with increasing enrollment of older adults who are more medically and socially complex and more racially and ethnically diverse. Legislative and regulatory oversight of MA has lagged behind its growth. Here we review key aspects of MA pertinent to older adults and those with serious illness, and we highlight recent major federal policies shaping MA.

Recent Findings

While MA was initially developed to provide cost savings, generate innovations in care, and improve healthcare quality, data indicate that costs are higher and quality is variable as compared to traditional Medicare. Development of functional impairment or worsening illness are associated with people switching from MA to traditional Medicare, which raises concerns about whether MA can adequately meet the needs of complex older adults. Recent legislative and regulatory updates have allowed MA plans to expand supplemental benefits that target social determinants of health and offer access to palliative care. Regulations continue to work towards increased transparency around quality and marketing of MA plans.

Summary

MA has the potential to be beneficial for older adults and those with serious illness, but there remain challenges for those with increasing social and medical complexity. Now that 50% of older adults will have insurance coverage through MA, there is great need for thoughtful, patient-centered federal policies for MA to ensure quality care for older adults, especially the most vulnerable. Clinicians, educators, and researchers need to be aware of how MA works, its implications for older adults, and how the latest federal policy changes to MA will affect the practice of medicine and what care their patients can access.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. McGuire TG, Newhouse JP, Sinaiko AD. An economic history of Medicare part C. Milbank Q. 2011;89:289–332.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Neuman P, Jacobson GA. Medicare advantage checkup. NEJM. 2018;2163–2172.

  3. • Freed M, Biniek JF, Damico A, Neuman T. Medicare Advantage 2023 Spotlight: First Look. 2022. KFF https://www.kff.org/medicare/issue-brief/medicare-advantage-2023-spotlight-first-look/. Accessed 9 Jan. 2023. Kaiser Family Foundation analysis showing increasing Medicare Advantage plans and growth trends across the United States over time.

  4. • Freed M, Biniek JF, Damico A, Neuman T. Medicare Advantage in 2022: Enrollment Update and Key Trends. 2022. KFF https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2022-enrollment-update-and-key-trends/. Accessed 9 Jan. 2023. Kaiser Family Foundation analysis showing increasing Medicare Advantage enrollment and beneficiary characteristics across the United States over time.

  5. Jacobson G, Cicchiello A, Sutton JP, Shah A. Medicare Advantage vs. Traditional Medicare: How Do Beneficiaries' Characteristics and Experiences Differ? The Commonwealth Fund. 2021. https://www.commonwealthfund.org/publications/issue-briefs/2021/oct/medicare-advantage-vs-traditional-medicare-beneficiaries-differ Accessed 1 Jan. 2023.

  6. Kumar A, Rivera-Hernandez M, Karmarkar AM, Chou L-N, Kuo Y-F, Baldwin JA, Panagiotou OA, Burke RE, Ottenbacher KJ. Social and health-related factors associated with enrollment in Medicare Advantage plans in older adults. J Am Geriatr Soc. 2020;68:313–20.

    Article  PubMed  Google Scholar 

  7. Muhlestein D, Smith N. Medicare Advantage Now Chosen By The Majority Of Minority And Low-Income Beneficiaries. Health Aff Forefr. 2022. https://doi.org/10.1377/forefront.20221220.223475.

    Article  Google Scholar 

  8. July 2022 Data Book: Health Care Spending and the Medicare Program – MedPAC. 2022. https://www.medpac.gov/document/july-2022-data-book-health-care-spending-and-the-medicare-program/. Accessed 4 Feb. 2023.

  9. • Biniek JF, Cubanski J, NeumanT. Higher and Faster Growing Spending Per Medicare Advantage Enrollee Adds to Medicare’s Solvency and Affordability Challenges. 2021. KFF https://www.kff.org/medicare/issue-brief/higher-and-faster-growing-spending-per-medicare-advantage-enrollee-adds-to-medicares-solvency-and-affordability-challenges/. Accessed 9 Jan. 2023. Kaiser Family Foundation analysis showing that beneficiaries enrolled in Medicare Advantage cost more than similar beneficiaries enrolled in traditional Medicare.

  10. Gilfillan R, Berwick DM. Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine’, Part 2: Building On The ACO Model. Health Aff Forefr. 2021. https://doi.org/10.1377/forefront.20210928.795755.

    Article  Google Scholar 

  11. Medcare Payment Advisory Commission. The Medicare Advantage program: Status report and mandated report on dual-eligible special needs plans. 2022. https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_Ch12_SEC.pdf. Accessed 28 Jan. 2023.

  12. Office of Inspector General. Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care. 2022. https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf. Accessed 9 Jan. 2023.

  13. • Biniek JF, Sroczynski N. Over 35 Million Prior Authorization Requests Were Submitted to Medicare Advantage Plans in 2021. 2023. KFF. https://www.kff.org/medicare/issue-brief/over-35-million-prior-authorization-requests-were-submitted-to-medicare-advantage-plans-in-2021/. Accessed 2 Feb. 2023. Kaiser Family Foundation analysis revealing that prior authorizations are very common in Medicare Advantage and most denials will be overturned if the time and effort are taken to appeal.

  14. American Medical Association AMA prior authorization (PA) physician survey. 2023. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf. Accessed 2 Feb. 2023.

  15. •• Agarwal R, Connolly J, Gupta S, Navathe AS. Comparing Medicare Advantage and traditional Medicare: A systematic review. Health Aff Proj Hope. 2021;40:937–44. One of the few systematic reviews comparing patient metrics like utilization, health care spending, quality of care, readmission rates, mortality rates, experience of care, and racial and ethnic disparities between Medicare Advantage and traditional Medicare. There are some improvements in quality, but not patient experience nor other important patient outcomes.

    Article  Google Scholar 

  16. • Ochieng N, Biniek JF. Beneficiary Experience, Affordability, Utilization, and Quality in Medicare Advantage and Traditional Medicare: A Review of the Literature. 2022. KFF. https://www.kff.org/medicare/report/beneficiary-experience-affordability-utilization-and-quality-in-medicare-advantage-and-traditional-medicare-a-review-of-the-literature/. Accessed 2 Feb. 2023. Kaiser Family Foundation review of 62 studies published since 2016 that examines beneficiary satisfaction and quality of care are minimally different between Medicare Advantage and traditional Medicare.

  17. Meyers DJ, Mor V, Rahman M. Medicare Advantage enrollees more likely to enter lower-quality nursing homes compared to fee-for-service enrollees. Health Aff Proj Hope. 2018;37:78–85.

    Article  Google Scholar 

  18. Schwartz ML, Kosar CM, Mroz TM, Kumar A, Rahman M. Quality of home health agencies serving traditional Medicare vs Medicare Advantage beneficiaries. JAMA Netw Open. 2019;2: e1910622.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Skopec L, Zuckerman S, Aarons J, Wissoker D, Huckfeldt PJ, Feder J, Berenson RA, Dey J, Oliveira I. Home health use in Medicare Advantage compared to use in traditional Medicare. Health Aff Proj Hope. 2020;39:1072–9.

    Article  Google Scholar 

  20. Meyers DJ, Trivedi AN, Mor V, Rahman M. Comparison of the quality of hospitals that admit Medicare Advantage patients vs traditional Medicare patients. JAMA Netw Open. 2020;3: e1919310.

    Article  PubMed  PubMed Central  Google Scholar 

  21. U.S. Government Accountability Office. Medicare Advantage: CMS Should Use Data on Disenrollment and Beneficiary Health Status to Strengthen Oversight. 2017. https://www.gao.gov/assets/gao-17-393.pdf. Accessed 30 Jan. 2023.

  22. Ankuda CK, Ornstein KA, Covinsky KE, Bollens-Lund E, Meier DE, Kelley AS. Switching between Medicare Advantage and Traditional Medicare before and after the onset of functional disability. Health Aff Proj Hope. 2020;39:809–18.

    Article  Google Scholar 

  23. CMS Office of Minority Health in Collaboration with the RAND Corporation. Disparities in Health Care in Medicare Advantage by Race, Ethnicity, and Sex. 2020. https://www.cms.gov/files/document/disparities-health-care-medicare-advantage-race-ethnicity-and-sex.pdf. Accessed 2 Feb. 2023.

  24. Park S, Werner RM, Coe NB. Racial and ethnic disparities in access to and enrollment in high-quality Medicare Advantage plans. Health Serv Res. 2022. https://doi.org/10.1111/1475-6773.13977.

    Article  PubMed  Google Scholar 

  25. DuGoff EH, Boyd C, Anderson G. Complex patients and quality of care in Medicare Advantage. J Am Geriatr Soc. 2020;68:395–402.

    Article  PubMed  Google Scholar 

  26. Rahman M, Keohane L, Trivedi AN, Mor V. High-cost patients had substantial rates of leaving Medicare Advantage and joining traditional Medicare. Health Aff Proj Hope. 2015;34:1675–81.

    Article  Google Scholar 

  27. Li Q, Trivedi AN, Galarraga O, Chernew ME, Weiner DE, Mor V. Medicare Advantage ratings and voluntary disenrollment among patients with end-stage renal disease. Health Aff (Millwood). 2018;37:70–7.

    Article  PubMed  Google Scholar 

  28. Tumlinson A, Burke M, Alkema G. The CHRONIC Care Act of 2018: Advancing Care for Adults with Complex Needs. 2018. https://www.thescanfoundation.org/sites/default/files/chronic_care_act_brief_030718_final.pdf. Accessed 15 Jan. 2023.

  29. Thomas KS, Durfey SNM, Gadbois EA, Meyers DJ, Brazier JF, McCreedy EM, Fashaw S, Wetle T. Perspectives of Medicare Advantage plan representatives on addressing social determinants of health in response to the CHRONIC care act. JAMA Netw Open. 2019;2: e196923.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Centers for Medicare and Medicaid Services. Reinterpretation of “Primarily Health Related” for Supplemental Benefits. 2018. https://www.hhs.gov/guidance/document/reinterpretation-primarily-health-related-supplemental-benefits. Accessed 4 Feb. 2023.

  31. Rowen NP, Stewart L, Saunders RS. Evaluation of supplemental benefits across Medicare Advantage plans and beneficiary demographic characteristics, 2019 to 2022. JAMA Netw Open. 2022;5: e2233020.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Advisory ATI. Advancing Non-Medical Supplemental Benefits in Medicare Advantage. 2022. https://atiadvisory.com/resources/advancing-non-medical-supplemental-benefits-in-medicare-advantage/. Accessed 10 Jan. 2023.

  33. Center for Medicare and Medicaid Innovation. Calendar Year (CY) 2024 Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model Fact Sheet. 2022. https://innovation.cms.gov/media/document/vbid-cy2024-rfa-fact-sheet. Accessed 9 Feb. 2023.

  34. Ankuda CK, Kelley AS, Morrison RS, Freedman VA, Teno JM. Family and friend perceptions of quality of end-of-life care in Medicare Advantage vs traditional Medicare. JAMA Netw Open. 2020;3: e2020345.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Centers for Medicare and Medicaid Services. Special Needs Plans. 2021. https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans. Accessed 4 Feb. 2023.

  36. SNP Alliance. Special Needs Plans & Medicare Advantage. 2023. https://snpalliance.org/what-we-do/about-snps/. Accessed 4 Feb. 2023.

  37. Centers for Medicare and Medicaid Services. CMS Releases 2022 Medicare Advantage and Part D Star Ratings to Help Medicare Beneficiaries Compare Plans. 2022. https://www.cms.gov/newsroom/press-releases/cms-releases-2022-medicare-advantage-and-part-d-star-ratings-help-medicare-beneficiaries-compare. Accessed 13 Sept. 2022.

  38. Centers for Medicare and Medicaid Services. Medicare Advantage and Prescription Drug Plan CAHPS (MA and PDP CAHPS). 2021. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/MCAHPS. Accessed 4 Feb. 2023.

  39. The National Committee for Quality Assurance. HEDIS. 2023. https://www.ncqa.org/hedis/. Accessed 4 Feb. 2023.

  40. The National Committee for Quality Assurance Communications. Improving care for those with advanced illness and frailty. 2018. https://www.ncqa.org/blog/improving-care-advanced-illness-frailty/. Accessed 28 Jan. 2023.

  41. Gabry-Kalikow S. The HEDIS Advance Care Planning Measure: What it is and Why it Matters. Adv. Care Plan. Decis. 2021. https://www.acpdecisions.org/the-hedis-advance-care-planning-measure-what-it-is-and-why-it-matters/#:~:text=The%20intent%20of%20the%20new,likely%20to%20benefit%20from%20it.%E2%80%9D Accessed 18 Jan. 2023.

  42. MacDonald I. Study: MA serves beneficiaries with higher social risk factors. 2020. https://www.risehealth.org/insights-articles/study-ma-serves-beneficiaries-with-higher-social-risk-factors/. Accessed 4 Feb. 2023.

  43. Centers for Medicare and Medicaid Services. Medicare Program; Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. Fed. Regist. 2022. https://www.federalregister.gov/documents/2022/05/09/2022-09375/medicare-program-contract-year-2023-policy-and-technical-changes-to-the-medicare-advantage-and. Accessed 4 Feb. 2023.

  44. Centers for Medicare and Medicaid Services. Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule CMS-0057-P: Fact Sheet. 2022. https://www.cms.gov/newsroom/fact-sheets/advancing-interoperability-and-improving-prior-authorization-processes-proposed-rule-cms-0057-p-fact. Accessed 4 Feb. 2023.

  45. Knight V (2022) Medicare Advantage has a marketing problem. 2022. https://www.axios.com/2022/09/08/medicare-advantage-marketing-problem. Accessed 7 Feb. 2023.

  46. The United States Senate Committee on Finance. Wyden Probes Deceptive Marketing Practices by Medicare Advantage Plans. 2022. https://www.finance.senate.gov/imo/media/doc/Deceptive%20Marketing%20Practices%20Flourish%20in%20Medicare%20Advantage.pdf. Accessed 30 Jan. 2023.

  47. Centers for Medicare and Medicaid Services. CY 2023 Medicare Advantage and Part D Final Rule (CMS-4192-F). 2022. https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-advantage-and-part-d-final-rule-cms-4192-f. Accessed 7 Feb 2023.

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Funding

Both authors declare they have no financial interests. Marian Grant has received consultant honoraria from the Coalition to Transform Advanced Care which has Medicare Advantage organization members. She does not have direct involvement with those members.

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Authors and Affiliations

  1. Department of Internal Medicine, Division of Geriatric Medicine, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA

    Deborah Grace Freeland

  2. University of Maryland School of Nursing, Baltimore, USA

    Marian Grant

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Correspondence to Deborah Grace Freeland.

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Freeland, D.G., Grant, M. A Review of Medicare Advantage Policy Through the Lens of Geriatrics and Palliative Care. Curr Geri Rep 12, 60–68 (2023). https://doi.org/10.1007/s13670-023-00386-4

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