There are certainly flaws in the mechanisms of the Med Advantage program, which few candid players dispute. You point them out here, but perhaps unfairly so. One example: untreated conditions for risk adjustment. This description fails to capture the true picture. Remember, this is not a fee for service model: in FFS, you only get paid if you produce a procedure. However, when a member has a chronic condition that merits a diagnosis, it is important to capture that diagnosis even if it is being well-managed with prescription drugs and is just being monitored. That is because the underlying condition poses a potential risk if not brought to the managing physician's attention at least annually and validated.
In an annual wellness visit (covered by Medicare), the annual recounting of all current conditions is important so that it can be determined whether the conditions really are well managed or if they deserve an intervention. This is a mindset shift for physicians.
Yet, if these conditions do not ever go away but the Med Adv plan fails to recapture them every calendar year, the payment levels to the Med Adv plan automatically drop. That is to say that there is no remaining risk residing in these chronic conditions and they are no longer being managed. That is how it works.
Gilfillan and Berwick are trenchant critics of the MA payment gravy train. Their prior HA articles on the plans' risk score gaming shed light on the rapid shrinking of FFS Medicare enrollment. But I question their premise here that MA plans shouldn't bid against FFS costs as increased by Medigap.
The choice between Medigap and MA is, fundamentally, a choice between a) access to care unimpeded by prior authorization and limited provider networks and b) extra services and reduced premiums "paid for" by giving up on those coverage advantages. All else being equal, offering enrollees a choice between FFS + Medigap's almost unlimited choice of providers and freedom from prior authorization vs. MA's extra services and (much) lower monthly costs might make sense -- or would, if you eliminated the advantages afforded MA plans via risk scoring, the current quality bonus system, and perhaps overly generous benchmarks.
For those unlucky 16% of FFS enrollees who have neither supplemental coverage nor dual eligibility, costs from out-of-pocket exposure doubtless inhibit needed as well as unneeded care. We've learned that "skin in the game," as defined in U.S. healthcare-speak, is more like a pound of flesh, leading people to forgo needed care and saddling them with debt. So average costs for naked FFS enrollees don't seem like a fair benchmark for MA.
There are certainly flaws in the mechanisms of the Med Advantage program, which few candid players dispute. You point them out here, but perhaps unfairly so. One example: untreated conditions for risk adjustment. This description fails to capture the true picture. Remember, this is not a fee for service model: in FFS, you only get paid if you produce a procedure. However, when a member has a chronic condition that merits a diagnosis, it is important to capture that diagnosis even if it is being well-managed with prescription drugs and is just being monitored. That is because the underlying condition poses a potential risk if not brought to the managing physician's attention at least annually and validated.
In an annual wellness visit (covered by Medicare), the annual recounting of all current conditions is important so that it can be determined whether the conditions really are well managed or if they deserve an intervention. This is a mindset shift for physicians.
Yet, if these conditions do not ever go away but the Med Adv plan fails to recapture them every calendar year, the payment levels to the Med Adv plan automatically drop. That is to say that there is no remaining risk residing in these chronic conditions and they are no longer being managed. That is how it works.
Gilfillan and Berwick are trenchant critics of the MA payment gravy train. Their prior HA articles on the plans' risk score gaming shed light on the rapid shrinking of FFS Medicare enrollment. But I question their premise here that MA plans shouldn't bid against FFS costs as increased by Medigap.
The choice between Medigap and MA is, fundamentally, a choice between a) access to care unimpeded by prior authorization and limited provider networks and b) extra services and reduced premiums "paid for" by giving up on those coverage advantages. All else being equal, offering enrollees a choice between FFS + Medigap's almost unlimited choice of providers and freedom from prior authorization vs. MA's extra services and (much) lower monthly costs might make sense -- or would, if you eliminated the advantages afforded MA plans via risk scoring, the current quality bonus system, and perhaps overly generous benchmarks.
For those unlucky 16% of FFS enrollees who have neither supplemental coverage nor dual eligibility, costs from out-of-pocket exposure doubtless inhibit needed as well as unneeded care. We've learned that "skin in the game," as defined in U.S. healthcare-speak, is more like a pound of flesh, leading people to forgo needed care and saddling them with debt. So average costs for naked FFS enrollees don't seem like a fair benchmark for MA.