More Health Systems Likely to Drop Out of Medicare Advantage, Analyst Predicts

Northeast Agent

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More health systems are going to be opting out of Medicare Advantage (MA) plans, George Hill, a managing director at Deutsche Bank in Boston, predicted Monday at a "Wall Street Comes to Washington" webinar hosted by the Brookings Institution.

"I think you're going to see more large provider organizations threaten to opt out of networks, particularly as it relates to MA," Hill said, adding that there are a number of reasons for this. "Prior authorizations are the problem, claims denials are a huge problem, delayed payments and rates are the problem -- barriers in access to care in all varieties are the problem."
This is stuff that happens all the time....providers cycle in and providers cycle out. Providers try to extort more money all the time. The only difference is Medicare Advantage has become a hot button issue the past year, so now you hear about it constantly and "the world is ending....AAAAAAHHHHHH!" Everyone knows healthcare providers like original medicare more because they can bill a unicorn and elephant and they will get it without question. Which is one of the reasons why healthcare costs taxpayers so much.....fraud, waste, and abuse.
There really needs to be some sort of standardized prior authorization process for the Providers when dealing with the MA organizations.

If CMS could make it happen, and provide some sort of training for the providers, it would be ideal.

I have spoken with providers in various places, sometimes, the person doing the billing and PA, have no background or experience. So, naturally they prefer the path of least resistance, OM.

How is the rise of Medicare Advantage impacting cancer care?

Medicare Advantage programs manage the cost by narrowing the network. Forty percent of Medicare Advantage plans don't have any NCI-designated centers in them. Twenty percent don't have an academic center in a field that is becoming more specialized, more complex. You're actually cutting off Medicare Advantage patients from more advanced therapies.

It makes a difference. In surgical oncology, your 30-day mortality rate for stomach and liver surgery is 50% higher in Medicare Advantage than in traditional Medicare. It's a 100% higher 30-day mortality rate for pancreatic surgery.

Narrow networks are great for primary care and secondary care. But when you really need highly subspecialized care, you need to have access to academic centers and high-volume centers. One of the risks of Medicare Advantage is that we're homogenizing care. It's a good program, except when you have complex care and you need a different solution.

What policies could improve access to cancer care for those with Medicare Advantage?

We need to modernize our definition of network adequacy. The current definition is based on board-certified oncologists within a certain number of miles. But the truth is, you need to have subspecialized expertise. You need to make a requirement that every network has access to an academic center for appropriate cases. Then, you need to define what those appropriate cases are.

In California, we formed a coalition called Cancer Care is Different Coalition. Through that coalition, we were able to enact a law called the California Cancer Care Equity Act that defines what complex cases are so Medicaid patients have a right to access academic centers if their network doesn't have appropriate expertise.

I think that needs to be a universal law. And in fact, we're starting in our Illinois site to work with a local legislature to create a bill of rights, and then we hope to turn that into a similar law. We want to have a national bill of rights and a national [access] requirement for Medicare Advantage. If you create that requirement, not only do you facilitate access into the academic center, but you're accelerating knowledge transfer. Not everything has to go to an academic center, often there's just a knowledge gap. Right now, somehow or another, we pitted community oncology against academic oncology, where it really should be a seamless ecosystem. We’ve let the economics create factions.
Seems like Dr. Levine is rehashing an old sermon. His City of Hope post is referenced by @Yagents

But as recently diagnosed cancer patients embark on this unwanted, unexpected care journey, what many seniors do not realize is that their Medicare Advantage (MA) plan can often put them at a disadvantage by restricting access to the care they need and deserve.

Nearly half of all Medicare beneficiaries are enrolled in MA plans, which equates to an estimated 29 million Americans. Unlike traditional Medicare, which allows patients to visit any hospital or physician that accepts Medicare, MA beneficiaries are only able to use physicians and hospitals within their plan’s — and in some instances, their sub-contracted medical group’s — network and service area.

While MA plans are ostensibly held accountable to maintain appropriate “network adequacy” to manage the primary and specialty care needs of their enrollees, many MA networks are woefully inadequate to ensure access to the latest advances most likely to help beneficiaries with cancer. This is because the industry has accepted, even encouraged, under the banner of affordability and, ironically, the catchphrase “value-based care,” plans to develop narrow networks. And for those developing these networks, the focus is on cost containment, and not the attributes most valued by cancer patients: survival, quality of life and additional years with friends and loved ones.

While this outcome may be unintended, it was not unforeseeable. Narrow networks can successfully provide coverage for less complex illnesses where expertise is abundantly available. But to understand why MA’s narrow networks negatively impact cancer patients, one must understand how cancer is different from other health concerns.

He has several articles and interviews in 2023 with the same theme. He is consistent but the message seems to fall on deaf ears.