Former CMS Administrator Weighs In: ‘I would like to see Medicare Advantage slowed or stopped’

From Becker’s

Medicare Advantage is now the dominant form of Medicare in the U.S., with a projected 54% share by the end of 2024, or more than 33 million enrollees.

According to January estimates from the Medicare Payment and Advisory Commission, Medicare Advantage plans will drive an additional $88 billion in payments to the program in 2024 compared with what traditional Medicare would receive.

Becker’s sat down with Don Berwick, MD, who served as CMS administrator during the Obama administration and is a current health policy lecturer at Harvard Medical School in Boston, to discuss where the Medicare Advantage program stands and potential reforms in the coming years.

Question: What are your broad thoughts on the state of Medicare Advantage as we start off 2024?

Dr. Don Berwick: I think the original ancestral idea of Medicare Advantage to allow Medicare beneficiaries to have the advantage of properly managed care that is coordinated, proactive and population-based was a healthy impulse 30 years ago. Based on the track record of the best managed health plans at that time, it could have reduced costs by a substantial amount, or about 10% to 15% lower costs compared to Medicare then. Who would not welcome better care and lower costs at the same time? But that’s not what happened.

Over time, financially driven interests, especially insurance companies, recognized that given the rules around Medicare Advantage, they could continually increase their revenue per beneficiary and make the program very attractive by offering zero premiums and extra benefits. It was quite a deal. Over the past decade, Medicare Advantage became the most profitable component of many major insurance companies around the country. It did not, in my opinion, fulfill its original promise of saving money. I’m thoroughly convinced now that apples to apples, Medicare Advantage plans cost the taxpayer, the Medicare trust fund and even beneficiaries, much more than traditional Medicare does.

Q: What changes would you like to see CMS make to Medicare Advantage?

DB: The most important ones right now are the ones they’ve started and should proceed with, which is to stop the coding issues. The most obvious and accessible is by upcoding patients by pouring diagnoses into their medical records and raising risk scores in ways that have nothing to do with their care. That’s money that goes right to the bottom line. I’d like to see CMS fix the risk rating system, in fact, I believe the HCC coding system should be basically ended and we should start again with a way to adjust payment that actually has to do with the needs of the patients enrolled. CMS did take a step toward that in 2023.

There are other elements of the payment system which get increasingly complex as you look at them. The quality bonus and star ratings system and the baseline county benchmark adjustments all need to be changed. I also think there should be more transparency around the exact contracts Medicare Advantage plans are signing and who they’re paying. In addition, there should be network requirements that are much more strict than the current requirements, and we need more patient-focused rules around network adequacy.

Q: CMS is seeking public feedback on how data collection and transparency around Medicare Advantage can be improved. It would seem that the government is on the right track for what you’re suggesting.

DB: Correct, and I commend them. There’s been courage and properly directed moves at CMS. However, CMS is always vulnerable, and the political forces that the agency has to contend with have and will push back hard on these changes. CMS needs a lot of support and encouragement from the administration and the public to continue on this journey, though I wish they would go faster and take on even more. For example, the risk coding changes are being implemented over three years unless the insurance industry finds a way to stop them. There are a lot more upcoding reforms that could be included in regulatory changes.

Q: Where is Medicare Advantage succeeding from your perspective?

DB: There certainly are Medicare Advantage plans who are honoring the original idea of truly coordinating care, putting the patient first and eschewing profiteering as their business model. Unfortunately, those are the minority of plans. The opportunity for profiteering is so great that if an MA plan wishes to behave properly — really coordinates care and does not withhold it or delay coverage for it — it would be probably regarded as naive in the business world.

Q: What do you want the future of Medicare to look like? Do you think that all seniors will eventually have no choice but Medicare Advantage?

DB: Given current growth rates and without substantial changes in the systems of payment, risk adjustment and transparency, I believe there’s a big threat that traditional Medicare as we know it will be atrophied significantly and that only the patients least desirable for insurers will end up with traditional Medicare. I’m very concerned and it’s highly unstable right now.

The benchmarks for Medicare Advantage are basically based on the expense pattern of traditional Medicare, so the whole financing calculation system is put in jeopardy by the dominance of Medicare Advantage. I would like to see Medicare Advantage slowed or stopped right now, or at least forced to have better carriers. Insurers need to be held accountable for lowering costs and improving quality at the same time — and lower costs are lower costs, not a calculation game of revenue that leads to an unfair distribution of Medicare expenditures.

The other part of the solution is to improve traditional Medicare with benefits expanded to be on par with Medicare Advantage. It should be cost neutral to beneficiaries as to which they choose. The money needed to improve traditional Medicare would be readily accessible by clawing back the excess subsidies that have accumulated for Medicare Advantage. Let’s have a fair comparison of traditional Medicare under public guidance with free choice for members to go any way they want and with reporting and quality standards that are enforced directly by CMS.