The "Problems" with Medicare Advantage

The Medicare Advantage program will become the dominant reimbursement methodology for the federal program by 2025. These authors lament the problems that will cause. “This development creates significant challenges for the Medicare program and some important issues for the larger health care system.

….Other challenges posed by the decline in traditional Medicare enrollment have been less widely recognized. They involve the potential loss of the vital role that traditional Medicare has had in shaping the health care system generally. Traditional Medicare has led the way in developing quality standards and measures that have been widely applied and in transparently sharing results with the public. The resulting quality data provide unique insight into the performance of the US health care system and can help purchasers and consumers of health care in both the public and private sectors choose among alternative sources of care.

Similarly, traditional Medicare claims data provide the only nationwide source of consistent, comparable information on patterns of care throughout the country. The standardized national benefits and cost-sharing in traditional Medicare eliminate a source of variability that complicates using data from private plans (when made available), including data from both Medicare Advantage plans and commercial insurance. Medicare claims data enable researchers to more accurately characterize differences in clinicians’ and health care centers’ approaches to similar illnesses and understand the drivers of health care spending. For example, traditional Medicare data have enabled important observations about variability in care within and across geographic areas, and have informed policies to reduce the variation, reduce unnecessary spending, and improve the quality of care.”

We should not mourn the passing of fee-for-service Medicare. It has failed utterly in shaping the healthcare system to deal with the major driver of excessive healthcare costs. Chronic disease generates 86% of all healthcare spending and the fee-for-service reimbursement system is the greatest barrier to better health at lower cost. “Medicare Advantage plans rely on capitated payments that are deemed to be value based.” Those capitated payments are based on traditional Medicare costs in that region. When your primary care cardiometabolic team takes care of Medicare patients with diabetes and heart disease using advanced systems and protocols, you will provide that care for much less and the savings will support your work very well. The most effective care is the least expensive care. We should all applaud the fact that Medicare Advantage will drive the entire American healthcare system to a value-based model.

The author does raise a legitimate concern. Medicare Advantage program are private and their data is private. American taxpayers are paying the bill and all voters should demand aggressives quality improvement efforts and transparency from all Medicare Advantage plans. How many patients are achieving optimal medical therapy for diabetes and heart disease? What is the impact of your plan on costs per patient per year by category. How are individual doctors and medical groups performing. Americans need that information to select their provider of care and they should demand it. We are all paying the bill. Minnesota is already providing public reporting on every medical group in that state. We should all push for more rapid adoption of Medicare Advantage and easier access to that model for provider teams.