Provider groups are joining in payers' concerns about CMS' proposed changes to Medicare Advantage risk adjustments and diagnosis coding.
In comments submitted to CMS March 6, the American Medical Group Association wrote that the agency should delay the implementation of the proposed switch to shifting MA's diagnosing coding to ICD-10 and reconsider removing certain codes from the Hierarchical Condition Categories model.
Risk adjustment is the system used by CMS to pay Medicare Advantage plans based on each beneficiary's health risk. The risk adjustment changes are part of a suite of changes — including shifting MA's diagnosis coding from ICD-9 to ICD-10 in 2024, which is used by more physicians, — the agency proposed in a notice issued Feb. 1.
In a statement, Jerry Penso, MD, AMGA's president and CEO, said the agency needs to allow more time for feedback on the changes.
"Modifying the HCC model is not a simple technical update or revision," Dr. Penso said. "It's likely to have significant ramifications, affecting both plans and providers."
CMS will issue a final ruling on the advance notice by April 3.
Insurers have also urged the agency not to implement its proposed changes, arguing the updates to the risk adjustment system represent a cut in funding to plans.
A Feb. 15 report from consulting firm Avalere Health, commissioned by the Better Medicare Alliance, a pro-MA group, found the proposed rule from CMS would result in a $45 per member per month decrease in payments to plans, or a $540 decrease in benefits per member per year.
HHS has said the risk adjustments are "unequivocally not cuts" in response to insurers' claims the changes will cut into MA members' benefits. CMS says the proposed changes will result in a 1.03 percent increase in payments to plans.
The Medical Group Management Association also urged the agency to delay implementing risk adjustment changes. In comments to CMS, the association asked the agency to provide more transparency about the estimated effects of its proposed coding revisions.
"While MGMA shares concerns about abuse in the MA program, we are concerned that this overhaul of the CMS-HCC model may result in unintended consequences that could impact beneficiary
access to care and impede important value-based care initiatives critical to the success of medical group practices," the association said.
Concerns about equity, patient outcomes
AHIP, the trade association representing the health insurance industry, and other groups, expressed concern in comments to CMS that the proposed changes could affect dual-eligible beneficiaries in particular.
Dual-eligible beneficiaries qualify for both Medicare and Medicaid on the basis of income or other factors.
"On balance, we believe the policies in the Advance Notice will threaten the stability of benefits for over 30 million seniors and individuals with disabilities, many of whom are low-income and have high healthcare needs," AHIP President and CEO Matt Eyles wrote in comments to CMS.
Cheryl Phillips, MD, president and CEO of the SNP Alliance, an organization representing dual-eligible plans, said in comments to CMS that the organization believes the effect on dual-eligible beneficiaries is "dramatically greater" than the agency's estimates.
"The impact includes providers, many of whom are in value-based payment models with health plans, and beneficiaries who will see increased premiums (where allowed) and decreased supplemental benefits," Dr. Phillips said.
The National Health Council, which represents more than 100 healthcare organizations, including the American Cancer Society and American Diabetes Association, said in comments to CMS it has historically supported proposals that encourage health plans to enroll a "higher proportion of chronically ill and disabled individuals."
In its comments, National Health Council CEO Randall Rutta said it is unclear if the proposed risk adjustment changes would do so.
"This proposal could result in lower payment for some MA plans based on their enrollment mix which could result in reduction of important benefits or increased cost-sharing to people with these conditions and — worse — further incentivize cherry-picking of healthy enrollees," Mr. Rutta said.