Researchers
shed light on the barriers that payers face in designing and implementing
Medicare Advantage supplemental benefits and offer some solutions.
December 10, 2019
- Medicare Advantage plans are slow in creating benefits that serve more
than medical needs for severely ill members, potentially because designing and
implementing a new healthcare benefit is challenging and time-intensive,
researchers from the Duke-Margolis Center for Health Policy found.
“The Medicare
Advantage market is a fertile testing ground for new care delivery models for
people with serious illness,” said Robert Saunders, PhD, research director at
the Duke-Margolis Center for Health Policy and one of the study’s co-authors
“The program’s
capitated payment structure encourages new approaches because plans share in
cost savings, earn bonus payments, and receive rebates (that they can use to
offer enhanced benefits or reduce member cost sharing) if they are able to
reduce costs while maintaining or improving the quality of care delivered, as
measured by Medicare’s Star Ratings program.”
But plans are
implementing supplemental benefits slower than many expected.
The study found that
between 2019 and 2020 the number of plans taking advantage of greater
supplemental benefit laxity was rising but not impressive.
Sixty-three plans added an adult day care benefit for severely ill members. A
total of 148 plans will offer in-home support and 58 will offer palliative care
benefits, both double the number of plans that did so last year.
Perhaps in response
to the opioids crisis, which has seen major headlines in the past few months as
last year’s lawsuits settle, the most impressive shift
has been in the number of plans offering non-opioid pain management benefits.
Whereas 24 offered non-opioid pain management benefits in 2019, 201 will be
offering such benefits in 2020.
Among plans that did
decide to develop more advanced MA benefits, the researchers noted a couple of
trends.
Plans serving urban
demographics were more likely to offer serious illness supplemental benefits,
with nearly 50 percent of areas that had a serious illness supplemental benefit
identifying as urban. Also, areas with higher concentrations of MA plans tended
to have greater access to supplemental benefits, with on average 32 percent MA
plan penetration for 2020.
These trends help
illuminate the challenges health plans face in implementing new supplemental
benefits.
For example, despite
wider parameters for supplemental benefits, plans have difficulty financing the
changes. They are being asked to make new benefits for Medicare beneficiaries
without receiving new funds. For many, this means reworking existing benefits
to incorporate serious illness supplemental benefits instead of creating new
benefits.
As the high urban
demographic indicates, rural regions incur challenges due to shortages of
palliative care providers, fewer community resources, and social determinants
of health barriers to home healthcare.
Relationships with
community-based organizations can pose difficulties as well, as they do not
always have the resources and experience to deliver benefits such as palliative
care or home healthcare. Furthermore, the small size of these organizations can
require plans to contract with many organizations in order to cover their
membership, which can be complicated.
Lastly, developing a
social determinants of health strategy for MA seemed counterintuitive to
payers. Some struggled to justify creating a new social determinants of health
strategy for their MA plans when they already had an approach in place across
all products. Others said that other plans’ social determinants of health
approaches were by its nature incompatible with MA.
Plans informed the
researchers that regulatory changes were one barrier to implementing more
benefits. The short timeframe given for developing benefits when expansions
were announced in 2018 and the drug rebate rule
were particularly challenging to work around.
“The bar is set high
for offering new supplemental benefits but progress is being made,” said
Saunders. “Designing and implementing new supplemental benefits, including for
patients with serious illness, requires rigorous evidence for how they will
impact clinical care quality, the health and quality of life of enrollees, and
overall health care costs.”
The researchers
suggested that plans should gather data to evaluate how members would use the
new benefit and its impact. Many plans try to do this through pilot programs.
However, pilots increase administrative burden and can have little buy-in from
consumers due to limitations on pilot program advertising.
Additionally, the
researchers found that payers would benefit from more specificity in cMS
regulations. While payers see the need for these benefits, it is hard for them
to formulate workable solutions based on the vague parameters given. Examples
from CMS would lend greater clarity.
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