Payers and providers have expressed concerns about CMS' proposed changes to Medicare Advantage risk adjustments and diagnosis coding.
Groups representing payers have said the proposed rate adjustments will force plans to either cut benefits or raise costs, and providers have said the agency's overhaul of the diagnostic coding system in Medicare Advantage could have unintended consequences for patient care and physician reimbursements.
CMS' proposed changes to risk adjustment, which is the system used by CMS to pay Medicare Advantage plans based on each beneficiary's health risk, include shifting MA's diagnosis coding from ICD-9 to ICD-10 in 2024, which is used by more physicians. The agency proposed this change and others in a notice issued Feb. 1.
CMS will issue a final ruling on the advance notice by April 3.
Here's what seven healthcare leaders have said about the proposal:
1. Matt Eyles, president and CEO of AHIP, the trade association representing health insurers, said the proposed notice would "increase costs and reduce benefits" for Medicare Advantage members, especially members who are dual-eligible Medicare beneficiaries.
"These lower-income enrollees are more likely to have multiple chronic illnesses and complex care needs," Mr. Eyles said. "We remain focused on strengthening and improving Medicare Advantage and urge the administration to pull back its flawed payment model revisions for 2024 and work with health insurance providers and other stakeholders to ensure MA is able to continue providing innovative, high-quality care to enrollees.”
2. Mary Beth Donahue, president and CEO of the Better Medicare Alliance, a pro-MA group backed by several insurers, said the changes would negatively impact outcomes for Medicare beneficiaries.
"Instead of proceeding with the risk adjustment changes, we respectfully request that CMS delay these changes, allow appropriate time for analysis, and work with stakeholders on clinically based revisions to the model," Ms. Donahue said. "Medicare Advantage seniors who choose Medicare Advantage need CMS to not move forward with these changes."
Additionally, 102 organizations, including several health systems, signed a letter led by the Better Medicare Alliance opposing the changes.
3. Ceci Connolly, president and CEO of The Alliance of Community Health Plans, which represents 37 nonprofit payers, said the alliance is overall supportive of the policy, which could level the playing field for smaller plans.
"While numerous health plans support moving forward with the entire new risk-adjustment model next year, CMS must recognize that the magnitude of the proposed changes are significant and highly variable," Ms. Connolly said. "As a result, many plans feel strongly that circumstances necessitate additional time and further information and are requesting a one-year delay of the reclassification portion of the risk-model update."
4.Randall Rutta, CEO of the National Health Council, which represents more than 100 healthcare organizations, including the American Cancer Society and American Diabetes Association, said the removal of some diagnostic codes could affect treatment for major depressive disorder, diabetes with chronic conditions, vascular disease, rheumatoid arthritis and inflammatory connective tissue disease.
"Further, 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. "This is particularly important as many patients may acquire or experience dramatic worsening of a chronic condition after enrolling in MA and face significant barriers if they try to move back to fee-for-service, such as limits on access to Medigap plans."
5. Susan Dentzer, president and CEO of America's Physicians Groups said the proposed changes could reduce payments to physicians for treating patients with diabetes, psychiatric conditions, musculoskeletal conditions, kidney conditions and vascular conditions.
"Although the overall effects will be felt unevenly across plans and medical groups, those hardest hit will be the entities making the greatest efforts to serve these populations and maintain their health and well-being," Ms. Dentzer said.
6. Cheryl Phillips, MD, president and CEO of the SNP Alliance, an organization representing dual-eligible plans, said the group thinks the effect of the proposed risk adjustment changes' effect on dual-eligible beneficiaries will be dramatically greater than CMS estimated.
"It is clear the impact disproportionately impacts those dually eligible and those enrolled in [chronic special needs plans] who are also often dually eligible," Dr. Phillips said. "While there is a wide range of impacts across plan types and geographies, the averages of impact don’t tell the real story for individual beneficiaries. This will directly impact premiums and decrease or eliminate supplemental benefits."
7. Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, said the group shares CMS' concerns about upcoding in Medicare Advantage, but asked the agency to pause implementation of changes to the coding system.
"If MA plans are upcoding to increase Medicare payments, they should be held fully accountable," Mr. Gilberg said. "It is unclear, however, if these [hierarchical condition categories] coding changes will only impact situations where abusive coding practices have occurred."