MA Stakeholders Take Issue With Bevy of Risk-Related Proposals

by Lauren Flynn Kelly

From payment related to the growing number of Medicare Advantage enrollees with end-stage renal disease (ESRD) to the proposed exclusion of 2020 data from risk score assumptions, several commenters responding to the 2023 preliminary rate notice questioned various factors that will be used to determine MA plan reimbursement next year. And while AHIP and other MA stakeholders voiced strong support for CMS keeping the coding intensity adjustment at the statutory minimum (5.9%) for 2023, the Medicare Payment Advisory Commission (MedPAC) took the opportunity to reiterate its contention that MA organizations are overpaid and that the adjustment does not adequately account for the differences in coding between MAOs and fee-for-service (FFS) Medicare.  

Payer trade groups signal support 

• AHIP, in its March 4 letter to CMS, said it strongly supports retaining that overall risk score reduction but asked for more detail around CMS’s proposal to exclude 2020 data in its annual “FFS normalization” adjustment, its assumption that 2023 FFS risk scores would return to pre-pandemic trends, how it will incorporate 2021 utilization data into the normalization factor for 2024, and how CMS arrived at the MA risk score trend of 3.5% for 2023. 
• AHIP also reiterated several prior recommendations, including two that would address the impacts of the COVID-19 pandemic: allowing plans to “carry over diagnosis codes for non-curable chronic conditions documented in prior years for purposes of determining enrollee risk scores” and the continued use of a weighting of 2 for calculating the patient experience/complaints and access measures in the 2023 Star Ratings. 
• Regarding ESRD, the Better Medicare Alliance in its March 4 comment letter urged CMS to transition “to a sub-state level to ensure payment and policies enable health plans and providers to offer high-quality care and treatment for beneficiaries with ESRD, without decreasing supplemental benefits or increasing premiums or the cost burden for all Medicare Advantage beneficiaries.” 
• The Alliance of Community Health Plans also voiced its support for studying and eventually moving away from the state-based method of determining ESRD rates. At the same time, it asked that CMS study the possibility of including a quality bonus payment related to care coordination for ESRD beneficiaries. 

MedPAC: Replace mandatory adjustment 

• Looking at available data for the last 14 years of payment adjustments, MedPAC estimated that the impact of coding intensity on MA risk scores has consistently exceeded the adjustment for coding pattern differences. 
• If CMS continued to apply the minimum 5.9% adjustment, Medicare spending for coding intensity would grow by $16.2 billion next year, for a total of more than $107 billion since 2007, MedPAC estimated. 
• Furthermore, applying the 5.9% adjustment across all contracts creates payment inequities between those that code more aggressively and those coding more like FFS Medicare, the commission observed.
• As a result, MedPAC suggested that CMS consider the commission’s prior recommendation for a “multipronged” approach to addressing MA overpayment, which it also included in its latest report to Congress. 

From Radar on Medicare Advantage

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