Equity And Access Are At The Forefront Of Proposed Medicare Advantage Changes

Each year, the Centers for Medicare and Medicaid Services (CMS) propose changes to Medicare Advantage (MA), a private health insurance option for people who are eligible for traditional Medicare. While the roughly 1,000-page document includes numerous noteworthy changes, health equity and access priorities feature prominently throughout the 2024 proposed rule.

The proposed changes have the potential for enormous impact. More than 28 million people are enrolled in these plans, estimated at about half of the eligible Medicare population, according to a Kaiser Family Foundation brief. In 2022, Medicare Advantage Plans represented about 55% or $427 billion of federal Medicare spending, not including premiums.

Medicare Star Ratings guide consumers, but raise equity concerns

Medicare Advantage's Star Rating system was created as a way of evaluating plans with a 5-Star Rating scale that assess factors from complaints to chronic disease management. The idea was to help shoppers seeking insurance better compare options on medical and prescription drug coverage. Along with guiding healthcare consumers, these ratings can have a big impact on health plan's bottom lines: higher Star Ratings can lead to bigger government financial incentives.

The ratings are tied to a complex series of factors including patient outcomes. Since financial rewards are given to plans with higher rates, there is concern that these rewards may compound existing inequities. People who have access to better plans will continue to see money flow into those plans. Meanwhile, plans may also have incentives to selectively pick healthier patients since better outcomes could drive up their ratings.

Over time, concerns and questions about the ratings have mounted, such as whether they accurately account for social risk factors that impact patient health. For example, in a 2021 Health Affairs article, researchers explored how these bonuses not only fail to improve quality but could lead to “a racially inequitable distribution of Medicare funds that disfavors Black beneficiaries."

Health equity reward programs

To address equity concerns, the government is proposing a new Health Equity Index that may be incorporated into the Star Ratings Program beginning in 2027. This new measure would create incentives to improve care for people with social risk factors.

The proposed expansion of the Medication Therapy Management (MTM) services could impact health equity as well. Under this provision, qualified beneficiaries receive a personalized pharmacist's review of their medications with the goal of reducing side effects and adverse events while improving health outcomes. The 2024 changes are designed to expand access by lowering the threshold to qualify for the services.

MTM is offered to beneficiaries who take multiple prescription medications and/or have chronic diseases, such as diabetes and hypertension. Overall, Medicare beneficiaries from historically marginalized populations have higher rates of chronic conditions, like hypertension and diabetes, than White beneficiaries, according to a 2021 Kaiser Family Foundation report.

Who can access culturally competent care?

Another change with a health equity component: plans would be required to provide culturally competent care to “an expanded list of populations" and improve access for people with limited English proficiency. This involves new standards for interpretation services and require that health education materials be available in alternative formats and additional languages.

According to the proposed rule, the expanded list would include people with limited English proficiency; people of ethnic, cultural, racial or religious minority groups; people with disabilities; people who identify as lesbian, gay, bisexual or other diverse sexual orientations; people who identify as transgender, nonbinary and other diverse gender identities or who were born intersex; people who live in rural areas and other areas with high levels of deprivation; and people who are otherwise adversely affected by persistent poverty or inequality.

Other steps addressing equity include requiring these plans to develop and maintain digital health education and including providers' cultural and linguistic capabilities in provider directories.

Streamlining prior authorization

Another key change addresses the use of “prior authorization" in MA plans and the impact on a beneficiary's access to care. Prior authorization refers to a pre-approval requirement for steps such as seeking specialists or out-of-network care. While the goal is to ensure the services are medically necessary, this administrative requirement has led to provider burnout and potential care delays for patients, notes Rise Health Care.

On the provider side, a report from the Association of Black Cardiologists, Inc. points to the high administrative burden of completing the prior authorization especially in practices that already grapple with low resources. This additional burden exacerbates already existent resource inequities and can have ripple effects on patient care and outcomes.

Prior authorization provision results in serious health impacts

In a survey of about 1,000 practicing physicians, more than 9 in 10 said prior authorization had a “significant" or “somewhat negative" clinical impact, and 34% reported the requirement resulted to a serious adverse event like hospitalization or death for a patient, according to a 2021 American Medical Association Survey.

In response, the new rules would take multiple steps to streamline this process and promote data sharing to address these potential care disruptions. Under the proposed change, plans would need to create an electronic process, shorten the time to respond to these requests and create policies to ensure greater transparency. Once an enrollee receives prior authorization, it will be valid for the full course of treatment.

On the plan side, CMS is proposing that all MA plans create an “Utilization Management Committee" to review local and national policies each year with the goal of keeping the coverage decision for these plans in line with traditional Medicare.

Cracking down on misleading health plan marketing

In response to concerns about misleading plan marketing, the new rule aims to address confusing and misleading advertisements to people shopping for MA coverage. There's been an uptick in misleading marketing tactics that lead some older adults to sign up for Medicare Advantage plans that don't cover their regular doctors or prescriptions and increase their out-of-pocket spending reported the Associated Press in 2022.

Bans try to protect beneficiaries

CMS is proposing a ban on ads that don't mention a specific plan name or ones that use the Medicare name or images in a misrepresenting way. The rule would codify policies that prevent “high pressure and misleading marketing." For example, the rule bans sales presentations that immediately follow an educational event and agents distributing business cards at these events. In addition, the Medicare's language and logo can't be used in a way that might trick enrollees into believing the ads are coming from the government.

More broadly, the rule requires agents to disclose all the plans they sell and inform potential clients where they can find complete Medicare options, such as the government web site and phone number.

Adding mental health capacities

In response to the country's mental health crisis and long wait times for appointments, the proposed rules would strengthen behavioral health adequacy in MA plans. The changes would add clinical psychologists, licensed clinical social workers, and people who can prescribe medications for opioid use disorder to the list of specialties. The rule suggests new minimum wait times for these behavioral health services.

Understanding the complexities

These are just a sample of the proposed changes expected to go into effect in 2024. RTI Health Advance can help you navigate these health equity and access-related changes as well as other key changes to Medicare Advantage plans and explore their impact on patients, plans and providers. Contact us today.