By Lori Gonzalez (2021)
Medicare Advantage (MA) enrollment has grown to include over 1/3 of Medicare beneficiaries since its authorization under the 2003 Medicare Modernization Act (MMA). The stated goals of the MMA were to use private plan alternatives to traditional Medicare to increase choice, benefits, and reduce cost. Nearly 2 decades later, it’s unclear if these goals have been realized due to a lack of encounter data, monitoring, and enforcement of plans’ contracts with the Centers for Medicare and Medicaid Services. This paper outlines the legislative history of MA and efforts to contain inappropriate payments and provides an overview of the relevant research findings. It concludes that the lack of encounter data and program accountability has incentivized private insurers to game the system and generate profits without significantly improving value in the Medicare program.
Medicare Advantage (MA), the private alternative to traditional Medicare, has gained in popularity among consumers over the last decade and today, almost 35 percent of those who are eligible for Medicare are enrolled in MA (KFF 2019). From the consumer perspective, MA is a good deal compared to traditional Medicare. MA plans are required to cover traditional Medicare Part A (hospital insurance) and Part B (medical insurance) using a per month per enrollee risk-adjusted capitated payment from Medicare. Most MA plans include other benefits like prescription drug coverage, fitness, vision, and dental. Premiums and cost-sharing are often lower than traditional Medicare and in 2011, legislation was passed limiting MA enrollees’ out-of-pocket expenses for Medicare Part A and Part B. These extra benefits and lower premiums and cost-sharing make MA an attractive alternative to traditional Medicare.
Interest in MA has also been increasing at the federal level. Growing concerns about the future of the U.S.’ Medicare program with soaring healthcare costs, an increase in the 65 and older population, and the hospital trust fund forecasted to be depleted by 2024 have given lawmakers a sense of urgency in a decades old battle about the role of private insurance in Medicare (HFMA 2021). While some Democratic congressional members envision a public option or Medicare for All, others including President Biden are committed to preserving MA with increased accountability and payment reform (Washington Post 2021). Republican congressional members largely support the private insurance market, especially MA (GOP-waysandmeans.house.gov 2020).
As consumer and congressional support for MA grows on the one hand, on the other hand, there’s an increasing body of research literature and government accountability reports that question the value of MA and its promise to produce cost savings while providing quality of care relative to traditional Medicare. This paper provides historical context for Medicare and private options, describes legislative changes in payments, and discusses the value of MA with regard to cost, health status of enrollees, access and utilization, and satisfaction with and quality of care.
In the early stages of the program’s development, insurance companies were surprisingly not opposed to Medicare. In fact, many understood that those age 65 and older are an expensive private insurance demographic, and many foresaw a role in providing supplemental plans (Swenson 2018). Furthermore, older people were viewed as an important share of voters and as having “worked hard all their lives as contributing members of society, who then needed assistance later in life, a situation many other contributing members will be in one day” and were, therefore, deserving of healthcare (Piatak 2017, pg. 1170). The arguments for providing healthcare to older people were clear and Medicare was enacted in 1965 under Title XVIII of the Social Security Act as an entitlement program to provide hospital and medical insurance to those 65 and older. Later, benefits were expanded to those younger than 65 living with certain medical conditions like end-stage renal disease. Medicare Part A covers hospital visits and is funded through payroll taxes; Medicare Part B covers physicians’ visits and is paid for by general revenue and premiums.
Private Alternatives Legislative Background
Private plans have always existed alongside traditional Medicare, primarily due to a desire to avoid disrupting plans provided by Health Maintenance Organizations (HMOs). HMOs (typically salaried physicians paid on a reasonable-cost basis) were paid via a fee for service (FFS) system or via a capitated rate (Berenson and Dowd 2008). The 1972 Social Security Act (SSA) changed how new private plans were paid, requiring them to operate on risk-sharing contracts—risk adjusted per capita costs with up to 20 percent to be shared with the government. The 1972 SSA also allowed demonstration projects to test different payment models with the goal of reducing cost and improving healthcare quality. Evaluations of the demonstration programs found that HMOs engaged in more preventative care and more conservative treatment of illness. The evaluation also showed that enrollees were more likely to be younger, rate their health as excellent, and were less concerned with having a single physician as their primary care doctor, compared to traditional Medicare beneficiaries. Despite these findings, HMOs were also estimated to be paid more for similar Medicare beneficiaries (Patel and Guterman 2017).
The 1980 Baucus Amendment offered Medigap insurers an optional certification status, thus bringing some Medigap plans under federal oversight (Rapaport 2012). In 1982, the Tax Equity and Fiscal Responsibility Act (TERFA) authorized the first private plans that could offer prospective, per enrollee payment or risk-based payments (Average Per Capita Cost Methodology or AAPCC). These plans were required to cover, at a minimum, Medicare benefits. Under these plans, enrollees paid Medicare part B premiums directly to Medicare and, if they elected, an optional prescription drug premium. Some plans also required an additional premium (McGuire et al. 2011). Under TERFA, Medicare pays HMOs 95 percent of the adjusted average per capita cost in the enrollee’s county of residence (Patel and Guterman 2017). HMOs were required to offer additional benefits to enrollees if their projected costs were lower than the federal government payments. These changes resulted in decreased hospital readmissions and shorter lengths of stay (Katz 2001).
The BBA of 1997 had the goal of expanding the number of private alternatives (e.g., creating Preferred Provider Organizations, Medical Savings Accounts, private fee-for-service, etc.) to Medicare (Gold 2014). It also aimed to correct for overpayments to plans by basing payments, in part, on health status and attempted to save money by increasing enrollees’ premiums. As a result, enrollment in private plans and the total number of plans dropped between 1999 and 2003 (Patel and Guterman 2017). Once again, however, private plans showed no cost savings relative to traditional Medicare.
The early 2000s saw several significant changes to private Medicare plans. In 2000, the Benefits Improvement and Protection Act based risk-adjusted payments on demographics and diagnoses (Principal Inpatient Diagnostic Cost Group or PIP-DCG). The new risk adjustment formula was gradually phased in over a period of 7 years to reduce the burden on existing plans. In 2003, the Medicare Modernization Act (MMA) replaced Medicare+Choice with MA plans. The MMA changed the way that MA plans were paid with plans submitting bids (their estimates of how much it would cost to cover the average enrollee for Medicare Parts A and B—including profits and administrative costs). If a plan’s bid is less than the benchmark (the maximum amount that a plan can be paid) then the plan receives their bid plus a percentage of the difference between the plan’s bid and the benchmark. Plans are also required to provide additional benefits. The MMA significantly increased payments to plans (Patel and Guterman 2017). It also allowed plans to offer Part D and introduced new plan options (regional PPOs and Special Needs Plans). In 2006, MA plans were required to provide Part D benefits, making MA plans attractive to those needing prescription benefits and subsequently, enrollment increased. In 2008, CMS introduced a 5-star quality rating system, based on the Healthcare Effectiveness Data and Information Set (HEDIS). A 2010 MedPac report found that regarding quality, enrollment, and access to care, MA plans were positive or stable—however, they were not cost effective with Medicare spending in 2009 about $14 billion more on MA enrollees than they would if they remained in FFS.
Reforms in the 2010 ACA reduced payments to MA plans, bringing them more in line with traditional Medicare (Patel and Guterman 2017). It also created bonuses for plans that are rated 3.5 stars or above, pays MA plans 95 percent of FFS costs in counties with high traditional Medicare costs, pays MA plans 115 percent of FFS costs in counties with low traditional Medicare costs, and established a medical loss ratio of less than 85 percent (Cubanski et al. 2015). The ACA also restricted cost sharing in MA plans for services to not exceed traditional Medicare’s. The most recent MPAC report (2019) suggests that the gap in payments to MMA versus FFS has been significantly reduced following all the legislative changes that have occurred over time despite increased payments to MA plans for quality improvements and higher risk coding.
Is MA a Good Deal?
Prima facie, MA is a good deal from the consumer perspective because premiums and cost-sharing are often lower than in traditional Medicare and plans offer additional benefits. In 2011, legislation was passed limiting MA enrollees’ out-of-pocket expenses for Medicare Part A and Part B to no more than $6,700 in network or $10,000 in network and out of network combined (KFF 2017; KFF 2019). By contrast, there are no limits to traditional Medicare beneficiaries’ out-of-pocket expenses. Cost sharing, however, has been found to increase in response to regulatory limits being placed on enrollees’ out of pocket inpatient and skilled nursing costs (Keohane et al. 2015).
Lower premiums, out-of-pocket expenses, and extra benefits are paid for by rebate dollars (a plan’s bid plus a percentage of the difference between the plan’s bid and the benchmark). Plans rated 3 stars or above by CMS receive additional reimbursement through quality bonuses that are tied to the benchmark with some urban, low-FFS and high MA enrollment counties receiving double bonuses (Congressional Budget Office.gov 2018). These perks are attractive to consumers—but could be more generous—representing less than half of the additional reimbursement plans receive (Duggan et al. 2016). Furthermore, questions remain about how well quality bonuses reflect actual enrollee satisfaction and plan quality, especially since MA enrollees are often healthier and use fewer services (Congressional Budget Office.gov 2018).
Whether MA is a good deal from the federal government’s and taxpayer’s perspective with regard to cost and spending is less clear. On the one hand, some county-level studies have associated increased MA market penetration with spillover effects including a decrease in FFS expenditures (Chernew et al. 2008; Commonwealth 2016; Garrett et al. 2016; Johnson et al. 2016) and lower hospital costs (Baicker et al. 2016; Baker et al. 2016). On the other hand, although MA plans often provide traditional Medicare benefits at a lower cost than FFS, the complex payment system described in the previous section results in MA plans being paid on average almost 10 percent more than their cost and 2 percent more than FFS (MedPAC 2020; Frakt 2016). Furthermore, changes to MA rules under ACA to better align cost to payments may encourage plans to engage in cost control methods that undermine the value of the program.
Determining whether MA is a good deal for consumers and the federal government has proven difficult largely due to the lack of quality encounter data showing detailed information on the health status of enrollees and the amount and frequency of services. In fact, two GAO reports (2014 2017) call for greater CMS accountability in terms of collecting and validating MA encounter data. However, there is evidence that MA may not be living up to its goals of providing quality coordinated care, increasing consumer choice, and providing cost savings to the Medicare program by enrolling higher morbidity individuals.
Health Status of Enrollees
One of the original goals of MA was to enroll high cost, high morbidity individuals to save costs to Medicare (McGuire et al. 2011). Yet, a longstanding finding in the research literature is that MA enrollees are healthier than FFS beneficiaries (Cabral et al. 2014; Kronich 2017). Miller and colleagues (2016), for example, compared MA enrollees to FFS beneficiaries between 2000 and 2005 to enrollees and beneficiaries in 2006 and 2009 and found that men and those with low morbidity made up most of the growth in MA enrollment. Early studies identified selective enrollment and targeted advertising in communities where healthier beneficiaries live as the primary mechanisms by which MA were gaining healthier, low-cost enrollees, prompting CMS to implement and refine over time a risk-adjusted payment system (Aizawa & Kim 2018; Brown et al. 2014; Kronich and Welch 2014; McWilliams et al. 2012; Newhouse et al. 2012). CMS risk adjusts diagnostic code information by age, disability, gender, and other factors to determine the capitated rate payment. The formula incentivizes plans to take on higher morbidity individuals to capture a larger payment (Jacobs & Kronick 2021).
Recently, the research literature has identified diagnostic upcoding as being the primary mechanism MA plans could use to generate a higher payment. Unlike FFS, MA plans are incentivized to report as many diagnoses as possible to increase enrollees’ risk scores, thereby increasing the plan’s payment (MedPAC 2019). Plans encourage providers to report all diagnoses and sometimes contact enrollees directly or send a nurse for a home visit to collect additional ones (MedPAC 2019). Brown and colleagues (2014) demonstrated that plans are aware of these incentives and likely use them to enroll individuals with diagnoses included in the risk score formulas and who they predict to be low-cost. Indeed, over the last decade, the average risk scores for MA have increased more than FFS by 1.5 percent per year without evidence that plans are taking on a larger share of higher morbidity individuals (Kronich & Welch 2014; Kronich 2017). Geruso and Layton (2020) calculated that compared to FFS, private Medicare plans generated between 6% and 16% higher risk scores, costing billions. In sum, it’s unlikely that MA is fulfilling one of its original goals—to take on enrollees with higher morbidity and to provide Medicare benefits at a lower cost than FFS.
Access to Care and Utilization
Another goal of MA was to use care coordination to reduce cost by driving down utilization rates. The research literature indicates that MA has been successful at keeping utilization rates lower than FFS’ for several measures as summarized below, although it’s not definitive, due to a lack of encounter data, as to whether the lower rates are reflective of better care coordination or if they are due to efforts to control access and use.
Effective care coordination is associated with a reduction in costly emergency department visits and hospitalizations (Veet et al. 2020) and several studies have demonstrated that utilization rates are lower for MA enrollees, compared to FFS. Parashuram and colleagues (2018), for example, examined ambulatory care and emergency department claims data and found that MA admissions to ambulatory care were about 1/3 less than FFS. Others have found that MA compared to FFS has lower emergency department use, ambulatory visits, lower relative resource use, fewer surgical procedures (expect for coronary bypass), and fewer hospital admission days (Baicker et al. 2013; Landon et al. 2012; Landon et al. 2015).
Other utilization studies have focused on hospital readmission rates and post-acute care. Several studies have found that MA enrollees have lower rates of hospital readmissions (Huckfeldtand et al. 2017; Kumar et al. 2018) with Lemieux and colleagues (2012) estimating that MA plans had between 13 percent and 20 percent lower readmissions. MA enrollees also have higher rates of discharge to the community and lower intensity post-acute care (Huckfeldtand et al. 2017), fewer days spent in a skilled nursing facility after discharge, and fewer average rehabilitation therapy minutes (Kumar et al. 2018). Recently, Park and colleagues (2020) found that MA enrollees compared to FFS beneficiaries had lower rates of healthcare utilization controlling for self-reported health status, across several settings including inpatient hospital, SNF, and primary care physician and that the difference was even more pronounced for those living with Alzheimer’s or related dementias. In sum, the research literature indicates that MA is better than FFS at controlling utilization of emergency department visits, hospital admissions, and hospital readmission, and post-acute care, although, without appropriate encounter data, it’s difficult to determine if the lower utilization rates are due to better care coordination, lower morbidity, or efforts to control costs.
Studies have also examined disenrollment and denials for care as factors that affect utilization patterns. MA plans set a limited network of providers and have high out of pocket costs for out of network care, while FFS beneficiaries can receive care virtually anywhere. A study (Timbie et al. 2017) compared MA to FFS in California, New York, and Florida found that FFS beneficiaries reported better access to care. Meyers and colleagues (2019) examined patterns of disenrollment among almost 14 million MA participants and found that 5 percent of high-needs Medicare beneficiaries and 15 percent of high-needs dual eligibles disenrolled from MA to FFS, compared to 3 percent of lower needs Medicare beneficiaries and 5 percent of dual eligible, indicating that MA plans were probably not serving the needs of those with poorer health. In an earlier study of disenrollment of end stage renal disease MA enrollees, Li and colleagues (2018) arrived at a similar conclusion. Riley (2012) found that MA disenrollees cost more when they move to FFS ($1,021 compared to their predicted $798 cost). Finally, almost 80 percent of MA enrollees are in plans that require pre-authorization for some services (KFF 2019). A 2018 OIG report found very high inappropriate levels (75 percent) of denials for care being overturned by Medicare Advantage Organizations raising questions about how often it occurs without appeal from providers or enrollees.
Enrollee Satisfaction and Quality
Researchers have examined differences between MA enrollees’ and FFS beneficiaries’ evaluations of their quality of care. Early research indicated that FFS beneficiaries had higher levels of satisfaction with their healthcare, compared to MA enrollees, however over time that gap has narrowed (Gold and Casillas 2014). Even so, satisfaction with care likely depends on health status with those MA enrollees with poorer health giving their MA plans lower ratings than comparable beneficiaries in FFS (Keenan et al. 2009; Elliott et al. 2011). A 2017 study by Timbie and colleagues found important nuances in how MA enrollees compared to FFS beneficiaries rated their plans in 3 large states. While MA enrollees rated their plans higher than FFS beneficiaries on 16 measures of quality (HEDIS and Part D measures), FFS beneficiaries reported better access to care. It’s unclear if enrollee health and utilization were taken into account, factors which would likely affect evaluations of their MA plans. Other studies have found that MA enrollees, compared to FFS beneficiaries, are admitted to lower quality hospitals (Meyers et al. 2020) and lower quality nursing homes (Meyers et al. 2018). Duggan and colleagues (2016) found that increases in reimbursements to plans didn’t improve urban-dwelling enrollees’ satisfaction with care on the Consumer Assessment of Healthcare Providers and Systems. They also found no increases in self-reported satisfaction with care in both urban and rural areas. Both findings indicate that although MA plans are being paid more, the higher payments don’t result in improved satisfaction with care.
CMS rates MA plans based on their quality on a 5-star rating system and awards bonuses to better performing plans. Over 60 percent of MA enrollees are enrolled in plans that are rated 4 or more stars, almost doubling in 2 years (KFF.org 2015). MA HMOs have been found to move enrollees into higher rated plans to achieve quality bonuses and often, enrollees don’t see an improvement in their quality of care. Part of the reason why enrollees don’t see an improvement is because the star rating system is based on plans’ performance relative to each other and the rating measures largely consist of process and administrative outcomes, not enrollee satisfaction or quality of care (MedPAC 2019).
MA was authorized with the intent to reduce costs to Medicare and with the promise of providing more efficient care to the high morbidity Medicare population. Instead, several regulations had to be imposed to reduce overpayment to MA plans. Furthermore, there is little evidence that MA plans are taking on higher needs individuals, unless the payment formula makes it lucrative. Another goal—providing enrollees with choice and introducing competition among plans—is yet to be realized with only 6 large MA insurers and 2 of those, UnitedHealthcare and Humana, enrolling almost 45 percent of all MA enrollees (KFF 2019). In 15 states, one insurance company dominates over half of MA enrollees (KFF 2015).
While the research literature indicates important differences between the health status of enrollees, access to care, utilization, quality of care, and cost, the ability to compare MA and FFS is severely limited due to a lack of MA encounter data (Brennan et al. 2018). Researchers have had to rely on snapshots of data and HEDIS data to try to evaluate MA. However, without claims data, it’s difficult to determine if research findings related to access to care and utilization in MA are due to restricted access or due to differences in care needs. In a similar vein, determining which is more cost effective—MA or FFS—largely depends on being able to determine the number and intensity of services provided, enrollee and beneficiaries’ needs, and health status. CMS should impose more stringent encounter data collection rules to facilitate future research and elucidate any benefits of MA compared to FFS. As it currently stands, MA might not be a good deal at the consumer or the federal level.
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