Medicare Advantage Must Promote Equity, Access, Affordability, and Curb Prior Auth Burdens

September 1, 2022

The Centers for Medicare & Medicaid Services (CMS) released a Request for Information seeking public comment on various aspects of the Medicare Advantage (MA) program as CMS works toward establishing more equitable, high-quality care in MA. The Association for Clinical Oncology (ASCO) submitted a response to the agency on a variety of issues including health equity, expanding access to coverage and care, promoting person-centered care, and supporting sustainability and affordability. Some of the issues addressed in ASCO’s comments are summarized below.

Health Equity

ASCO applauds CMS’ commitment to enhance health equity for all MA enrollees. The Association’s mission – conquering cancer through research, education, and promotion of the highest quality, equitable patient care – reflects ASCO’s own commitment to equity. To better ensure that MA beneficiaries with cancer receive the care they need, the Association makes a variety of recommendations in its comments.

ASCO supports the standardized collection of demographic elements and use of relevant data for quality improvement. MA plans should also leverage partnerships with community-based organizations to drive equitable care. Community-engaged strategies are essential to addressing the social determinants of health and ultimately achieving health equity.

CMS should ensure that MA plans do not employ marketing practices or benefit designs that would discourage the enrollment of individuals based on sexual orientation and gender identity. Additionally, ensuring equitable access to clinical trials is another way CMS can guarantee that patients with cancer receive the care they need in MA.

Expanding Access to Coverage and Care

During Medicare open enrollment, tens of millions of beneficiaries compare coverage options and enroll in a plan. For 2022, the average beneficiary had access to 39 MA plans. Navigating these options can be a difficult experience, as beneficiaries have questions such as whether to enroll in traditional Medicare or a MA plan, and how much such options will cost. To support beneficiaries in plan selection, CMS should ensure that MA plans provide enrollment and communication materials that are culturally appropriate and address the specific communication and language needs of MA beneficiaries. We also recommend that CMS ensure MA plans provide beneficiaries with condition-specific information on issues such as out of pocket costs and covered services under different plan types.

Prior Authorization

ASCO recommends that CMS alleviate the burdens associated with prior authorization on patients and providers by immediately following recommendations from the Office of Inspector General’s report on the impact of prior authorization in MA, including:

  • Issuing new guidance on the appropriate use of Medicare Advantage Organization (MAO) clinical criteria in medical necessity reviews
  • Updating audit protocols and directing MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors
  • Following CMS’ normal enforcement action process for noncompliant MAOs
  • Adding additional enforcement actions for MAOs that demonstrate a pattern of inappropriate payment denials

To align the data on prior authorization and other utilization management practices with the goal of improving access to high-quality, equitable cancer care, ASCO suggests payers—including MAOs—report data to CMS on:

  • patient use or prior authorization
  • timeliness of prior authorization request determinations
  • extent of prior authorization use
  • additional prior authorization requirements for added, medically necessary services performed during a procedure that already received prior authorization. 

Drive Innovation to Promote Person-Centered Care

Value-based contracting between MAOs and providers can generate cost efficiencies and improve clinical outcomes in MA—supporting the ultimate aims of payment reform. Similarly, advancing health equity has been appropriately embraced as a central goal of value-based contracting, with significant attention now being paid to how value-based arrangements should be designed.

ASCO supports CMS’ aim to align policies between MA and traditional Medicare’s value-based care programs and offers recommendations to decrease performance measurement discrepancies among programs and help expand value-based contracting in MA. Specifically, CMS should:

  • Include MA plans in initiatives such as Data at the Point of Care and the Beneficiary Claims Data API (BCDA)
  • Include MA plans in CMMI registries that collect sociodemographic, clinical, and quality data from providers
  • Include MA data in provider feedback reports
  • Share risk adjustment and trending methods to align performance and financial methods
  • Use solutions proffered by groups including medical specialty societies to establish and confirm required care transformations and practice redesign activities

Support Affordability and Sustainability

MA is playing an increasingly important role in the Medicare program, with enrollment doubling over the past decade and continuing to grow. While ASCO supports MA as an option for beneficiaries and acknowledges the potential of MA plans to coordinate and organize the health delivery system to improve care, there is considerable evidence that MA plans are overpaid relative to traditional Medicare. To improve the MA market and foster competition, CMS should look to make program improvements where the program’s payment system has failed to optimally promote high-quality care.

Read the full comment letter.

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