How Can We Make Medicare Advantage Better?
By Jarrod Fowler, MHA
FMA Director of Health Care Policy and Innovation | Updated March 24, 2022
As the FMA has reported previously, Florida is one of only two states where Medicare Advantage (MA) enrollees constitute the majority of beneficiaries. Additionally, MA enrollees are projected only to grow as a proportion of total Medicare beneficiaries in the coming years. Therefore, it will become increasingly important to focus on ways to improve MA from the standpoint of beneficiaries and physicians alike. Outlined below are two improvements to MA that could be enacted almost immediately and would have a positive impact on the program’s sustainability.
Enact Stricter Network Adequacy Standards
Medicare Advantage plans are already held accountable for having adequate networks under current law. Yet, no paucity of examples exist wherein patients switch back to original Medicare as they grow sicker, sometimes to gain access to subspecialists who may be harder to locate within their plans’ networks. While not all MA plans have narrow networks or issues with network adequacy, patients who enroll in any MA plan deserve to have a robust network of specialists and subspecialists.
In addition to the study on network adequacy required under the No Surprises Act (NSA), government agencies should invest more in ensuring that all MA plans have truly adequate networks and that beneficiaries can always get the specialized care they need without having to switch to traditional Medicare or another product.
Enact HR 3173 to Address Prior Authorizations
Greater transparency with prior authorizations, which can bog down access to care within the context of Medicare Advantage, is essential.
Evidence suggests that targeted, meaningful improvements to the MA prior authorization process could improve administrative efficiency and patient health outcomes. Physicians routinely cite prior authorization as both a top administrative burden and a top barrier to providing patients with timely medical care. For instance, survey data has found that 94% of physicians experience at least some delays in delivering treatments to their patients because of PA requirements. Additionally, 79% of physicians report that PA requirements have caused patients under their care to abandon their recommended courses of treatment. Moreover, 30% of physicians report that PA requirements have caused a patient under their care to experience a serious adverse medical event, such as being hospitalized or requiring emergency medical intervention.
Finally, PA requirements consume an average of 16 hours per week of physician time and 85% of physicians describe the burden of PA requirements as “high” or “extremely high.”i The FMA emphatically supports HR 3173, which includes multiple provisions that would reduce this type of harm and waste in the context of the Medicare Advantage program where patients are likely to require prompt and appropriate medical treatment. In particular, the bill would:
- Establish an electronic prior authorization (ePA) program and require MA plans to adopt ePA capabilities that meet specified standards. The adoption of appropriate ePA standards would lessen the administrative burden associated with PA requirements and support the advancement of interoperability.
- Require the Secretary of the Department of Health and Human Services (HHS) to establish and routinely update a list of items and services eligible for real-time decisions under the MA ePA program, taking into consideration current medical practice and technology, healthcare industry standards, and other relevant factors. Standardizing and streamlining the prior authorization process for routinely approved items and services would significantly reduce the amount of unnecessary time and effort spent on PA requests.
- The legislation requires PA requests to be reviewed by qualified medical personnel. The approval or denial of a PA request can greatly affect the health and well-being of vulnerable Medicare beneficiaries and such determinations should only be made by those with appropriate training and expertise.
- The legislation contains provisions that increase transparency around the PA process by requiring MA plans to provide certain data and information to CMS, providers, and beneficiaries. For instance, the transparency provisions in the bill require MA plans to provide detailed data on the applicability of PA requirements for covered items and services, the rate at which PA requests are approved, the manner in which PA appeals and denials are adjudicated, and other relevant data that will help government officials and stakeholders evaluate the benefits and drawbacks of PA requirements with greater precision.
- The legislation requires HHS to engage in rulemaking to protect beneficiaries from disruptions in care due to PA requirements as they transition between MA plans. Such protections will prevent Medicare beneficiaries from experiencing treatment delays when they exercise their right to change MA plans in accordance with current law.
Taken together, these five improvements would make strong steps toward a more fair and transparent prior authorization system that could be expanded to other types of health plans later.
i 2020 AMA prior authorization (PA) physician survey
, American Medical Association