Addressing Serious Illness Care in Medicare Advantage

With 48% of Medicare beneficiaries enrolled in the Medicare Advantage program,¹ the challenge of providing high-quality care for people with serious illness who are covered by such plans is pressing. Though it previously insured healthier beneficiaries than did traditional Medicare, on average, Medicare Advantage increasingly insures people with serious illness under special-needs plans that cater to beneficiaries who are dually eligible for Medicare and Medicaid, those residing in institutions, and those with certain chronic illnesses. Medicare Advantage enrollment has grown disproportionately among Black and Latinx people, so any quality deficiencies in the program may result in racial and ethnic disparities in quality of care and outcomes.

Although the goal of the Medicare Advantage program is to provide high-quality care that is coordinated, competent, equitable, and person-centered, plan administrators face financial incentives to contain costs, since they receive capitated payments and therefore may keep a portion of payments as profit. For enrollees with serious illness, who often require extensive care provided in multiple settings, the program’s cost-control mechanisms — such as coverage denials, narrow provider networks, and prior-authorization requirements — may undermine the ability to receive necessary or high-quality care. We believe a comprehensive approach that prioritizes improving data transparency and quality measurement is necessary to ensure that the Medicare Advantage program facilitates the delivery of high-quality and equitable care.

There are several challenges involved in improving the quality of care in Medicare Advantage for people with serious illness. Despite the program’s substantial growth, there aren’t sufficient data to evaluate the quality of care delivered to beneficiaries with serious illness, much less to assess disparities based on race, region, or dual-eligible status. For 3 consecutive years, the Medicare Payment Advisory Commission (MedPAC), on which one of us recently served, stated that it “can no longer provide an accurate description of the quality of care in [Medicare Advantage].”² Although plan-reported encounter data are now released to researchers, they are neither complete nor reliable,³ which makes assessing service delivery challenging.

One potential appeal of Medicare Advantage plans for people with serious illness is the availability of supplemental benefits that can address needs that are traditionally seen as nonmedical, including meal, transportation, and caregiver-support benefits. Yet information on the frequency with which plans offer these benefits, who they are offered to, how they are delivered, and their effects on quality of care and beneficiary experience isn’t available. Similarly opaque are changes in plan ownership that may influence care delivery by shaping provider networks and the involvement of outside contractors. Detailed and up-to-date information on provider networks is necessary to enable Medicare beneficiaries to understand differences among plans and to choose a plan that works with their preferred providers.

In addition to these limitations, we believe the quality bonus program (QBP), which offers incentives for providing high-quality care in Medicare Advantage, needs critical review and strengthening to improve accountability — steps that will be particularly important to support enrollees with serious illness. The foundation of the QBP is a five-star rating system in which plans are scored on the basis of claims-based performance measures and patient surveys. This system has a dual role: administrators receive financial rewards for having high-performing plans, and beneficiaries use the ratings as part of plan selection. A decade after the QBP’s implementation in 2012, however, concerns about its accuracy in measuring quality and its ability to drive quality improvement have been persistently documented in academic research and MedPAC reports.²

The inaccurate reflection of quality in the current rating system hampers its ability to provide appropriate incentives for plan administrators and to guide consumers. Part of the problem is that the system assesses quality at the level of Medicare Advantage contracts, which are aggregations of local plans, not the level of individual plans. Plans are the distinct benefit packages with various cost-sharing structures, supplemental benefits, and provider networks that are offered to Medicare-eligible people for voluntary enrollment. Multiple plans are often aggregated into larger contracts, which are administered by commercial health insurers, such as Humana and UnitedHealthcare. As a result, a Medicare Advantage contract may contain various plans with distinct structures that are offered over noncontiguous regions and multiple states. Beneficiaries using the Medicare.gov Plan Finder tool sponsored by the Centers for Medicare and Medicaid Services (CMS) may therefore lack the necessary information to assess a specific local plan. Despite CMS’s substantial investment in the QBP, there is no evidence that the program has improved the quality of care in Medicare Advantage.⁴

Moreover, in at least two important ways, the QBP fails to adequately measure the quality of care delivered to enrollees with serious and complex illness. First, people with serious illnesses, such as dementia, are undersampled in Medicare Advantage Consumer Assessment of Healthcare Providers and Systems surveys,⁵ which inform quality ratings in the program. As a result, these ratings rely too heavily on the experience of people with no or stable medical illnesses and those who have fewer health care needs and less difficulty navigating the health care system than do people with serious illness. Second, many QBP measures, such as those related to disease prevention, may be less relevant to people with serious illness than to people without serious illness. There is less emphasis on indicators that are especially important to the experience of people with serious illness and their caregivers — for example, those capturing high-quality communication or care coordination. Although it may be challenging to improve the QBP by implementing reporting of plan-level data or data specific to people with serious illness, given the small number of such enrollees in some plans, CMS should ensure that quality measures provide consumers with actionable data for choosing a local health plan. Further research and creative solutions are needed to determine how best to accomplish this aim.

Broad Recommendations and Potential Strategies for Improving the Care of People with Serious Illness in Medicare Advantage.^*

Recommendation	Potential Strategies
Improve the quality and actionability of data to support transparency	Increase transparency on the Medicare Plan Finder website by specifying the regions (e.g., counties) of residence for beneficiaries who contribute data to star ratings (immediate). Publicly report ownership changes, including acquisitions, mergers, and divestments, within Medicare Advantage that may influence service delivery (immediate). Begin the process of improving the quality of data reported and the data’s relevance to people with serious illness (immediate). Continue to improve the completeness of Medicare Advantage encounter data capturing service delivery, potentially by means of incentives or penalties (short term). Expand data reporting on supplemental benefits, including, at a minimum, data on the number or proportion of beneficiaries who receive a particular service (such as transportation assistance) and the frequency with which they receive it (short term). Ensure complete and timely publication of information on Medicare Advantage provider networks (short term).
Improve quality measurement to support accountability (particularly within the QBP) and quality improvement	Begin the process of identifying new strategies for capturing the experience of people with serious illness in Medicare Advantage (immediate): Administer additional Medicare Advantage CAHPS modules to certain populations, such as those with functional impairment and serious chronic illness or high health care utilization or recent hospitalizations, similar to what is done in the Health Outcomes Survey. Conduct a universal postdeath survey for all family members and close friends of decedents in Medicare Advantage plans. Focus more attention on nonresponse bias and revise interview approaches to ensure that the population of people with serious illness is adequately captured or oversampled. Report at least selected quality measures in a stratified manner to capture the experience of beneficiaries with greater-than-average health care needs. Report at least selected quality measures at the plan or region level.
Invest in critical review of the Medicare Advantage program	Congress could mandate and fund a NASEM report to provide an independent evaluation of the care of people with serious illness in Medicare Advantage, with attention to concerns related to the QBP (immediate): Focus the report on how to move forward with providing reliable and actionable data to support accountability for Medicare Advantage plans and a payment model that provides incentives for high-quality care. Require evaluations of the Medicare Advantage program to be more transparent and of higher quality, with additional outside review and scrutiny (short term). The NIH could develop requests for applications for targeted research on key areas related to care delivery, quality of care, and beneficiary and caregiver experience in Medicare Advantage and fund such projects (short term).

^*CAHPS denotes Consumer Assessment of Healthcare Providers and Systems, NASEM the National Academies of Sciences, Engineering, and Medicine, NIH the National Institutes of Health, and QBP the quality bonus program.

We believe several strategies could help address the concerns associated with current efforts to report on quality of care in Medicare Advantage (see table). These challenges are complex, however, and multiple stake-holders will need to contribute to developing the best approaches to confronting them. Congress could commission a report from the National Academies of Sciences, Engineering, and Medicine on quality of care in Medicare Advantage, with a focus on people needing complex and high-cost care, particularly those with serious illness. The National Institutes of Health could prioritize research on a range of issues related to care delivery in Medicare Advantage that merit focused investigation, such as beneficiary experience and the best approaches to measuring quality of care for people with serious illness. More immediately, the Medicare Plan Finder website could provide clearer context for the plan data it presents (e.g., by listing the regions from which quality data are derived), and CMS could begin the process of improving quality measures to ensure that they are locally relevant and capture the experience of people with serious illness. CMS could also start publishing data on plan ownership and take steps to make encounter data more complete, as well as require accurate reporting on networks and the delivery of supplemental benefits. Substantial progress could be made by means of ongoing evaluations of the Medicare Advantage program by CMS contractors, especially if the methods and results of these evaluations were more transparent and subject to external review.

Our concerns regarding care delivery for Medicare Advantage enrollees have been previously raised and echo years of analysis by researchers and MedPAC. Nevertheless, with the program projected to enroll up to 60% of Medicare beneficiaries by 2030, urgent reevaluation is needed. We believe the time has come for a forward-thinking approach aimed at reforming Medicare Advantage to better meet the needs of people with serious illness.