AMGA: Align Medicare Advantage, APMs to Promote Value-Based Care

January 23, 2018 - If CMS moves forward with relaxing Medicare Advantage benefit requirements, then the federal agency should offer the same flexibilities to providers and beneficiaries in Medicare Part B alternative payment models, such as accountable care organizations (ACOs), the AMGA recently contended.

Extending uniformity of benefits flexibilities to other Medicare parts would boost provider participation and success in value-based care models, as well as allow Medicare Advantage plans and alternative payment models to compete, the industry group explained.

Currently, Medicare Advantage plans abide by a uniformity requirement that mandates plan benefits and cost-sharing arrangements are the same for all plan enrollees.

However, CMS has been testing in several states if a value-based insurance design (VBID) can reduce spending while improving care quality for CMS-specified chronic conditions. VBID allows payers to “structure enrollee cost sharing and other health plan design elements to encourage enrollees to use high-value clinical services – those that have the greatest potential to positively impact enrollee health,” CMS explained on the demonstration’s webpage.

Medicare Advantage plans in the demonstration can, therefore, offer additional services or reduced cost-sharing to individuals with specific chronic conditions. But enrollees with the same conditions must receive uniform benefits and those with chronic conditions can never receive fewer benefits or face higher cost sharing than other plan enrollees.

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In the most recent CMS ruling on Medicare Advantage contract year 2019, the federal agency stated that it is “considering issuing guidance clarifying the flexibility MA [Medicare Advantage] plans have to offer targeted supplemental benefits for their most medically vulnerable enrollees.”

The guidance would include similar flexibility provisions as those in the VBID demonstration.

While AMGA backs the concept of VBID, the industry group expressed concerns that changing Medicare Part C, otherwise known as Medicare Advantage plans, will affect Part B and alternative payment models under Part B, such as the Medicare Shared Savings Program and other ACO models.

CMS should work to “synthesize” Medicare Parts B and C by extending uniformity flexibilities to providers and beneficiaries in Part B alternative payment models, AMGA suggested.

Leveling the playing field between Medicare Advantage and Part B would support, and increase, provider success in alternative payment models and ACOs. As a result, more providers would join ACOs as the chances to earn shared savings increase under uniformity flexibilities.

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More providers would also participate in the Advanced Alternative Payment Model (Advanced APM) track under MACRA, which is the ultimate goal of the value-based reimbursement program.

In addition, Medicare Advantage plans would have to compete with ACOs if both Medicare parts included uniformity flexibilities. Plans would have more incentive to motivate their contracted providers through value-based payments and bonuses to improve care value.

Medicare Advantage providers would also gain the opportunity to participate in the Advanced APM track because the Medicare Advantage plans would be motivated to include downside financial risk and other alternative payment model components.

Patients would also realize benefits from uniformity flexibilities in both Medicare Parts B and C. Competition between Medicare Advantage and Part B alternative payment models would lead to increased patient choice and decreased premium costs.

“In sum, Medicare would, finally, become a synergistic, coherent program or one greater than the sum of its parts,” AMGA stated.

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This is not the first time that AMGA called on CMS to harmonize its various parts and programs. In April 2017, the industry group urged CMS to align Medicare reimbursement policies across Medicare Advantage, fee-for-service models, and the Medicare Shared Savings Program.

“AMGA members are focused on providing the best care, and variation among CMS programs creates unnecessary impediments,” stated Chester A. Speed, JD, LLM, AMGA Vice President of Public Policy. “Unfortunately, depending on what type of Medicare coverage a patient has, the regulations governing coverage, payment, and quality reporting can vary dramatically. This creates an administrative burden that doesn’t serve the patient, the provider, or Medicare, itself.”

Misalignment also creates Medicare program inefficiencies, the industry group argued. Medicare programs across each part cannot compete when each part functions with different reimbursement, coverage, and quality reporting rules.

Competition between Medicare Advantage, fee-for-service, and ACO models is key to driving out inefficiencies by shifting the market away from low-value providers and plans, the industry group stated.

But the most recent consideration to grant flexibilities to Medicare Advantage and not other Medicare parts is yet another example of how the healthcare program is disjointed. Extending the same flexibilities to Medicare Part B could boost competition and particularly lead to ACO success, AMGA explained.

“Supplemental benefits are particularly important for chronically ill or medically vulnerable patients,” stated Jerry Penso, MD, MBA, AMGA President and CEO. “This flexibility in benefit design should be available to all Medicare beneficiaries.”

“This proposal is an opportunity to align the disparate parts of the Medicare program. Should CMS finalize this proposal, similar changes should be implemented across the entire Medicare program to ensure a level playing field.”