Lindsay Greenleaf Discusses the 2021 Medicare Advantage Rate and Related Effects of COVID-19

The American Journal of Managed Care® spoke with Lindsay Bealor Greenleaf, JD, MBA, Vice President of Policy, ADVI Health, about CMS’ recent enactment of the 2021 Medicare Advantage rate announcement, and the effects of COVID-19 on Medicare Advantage. This transcript has been edited slightly for clarity.

Transcript

AJMC^®: I'm Mary Caffrey for The American Journal of Managed Care^®. And I'm here today with Lindsey Bealor Greenleaf, vice president of policy at ADVI Health to discuss the 2021 Medicare Advantage rate announcement and how COVID-19 has affected Medicare Advantage. Welcome, Lindsay.

Greenleaf: Thanks for having me.

AJMC^®: Before we get into the specifics of the 2021 rate announcement, can you discuss the growth of Medicare Advantage in recent years and what that's meant for health plans?

Greenleaf: Sure. Medicare Advantage (MA) continues to grow each year with enrollment doubling over the last decade. Currently, we have 24 million enrollees in MA plans, and that represents about 38% of all Medicare beneficiaries. We expect this growth to continue. The Trump administration continues to give MA plans a lot of flexibilities with their benefit offerings and with tools to contain costs, which helps them to keep premiums low. So as long as MA plans are able to provide beneficiaries with more choices and keep premiums relatively low, they will certainly be a popular choice.

AJMC^®: One of the biggest concerns we hear from seniors—and everyone—is the cost of prescription drugs. Can you talk specifically about how Medicare Advantage is encouraging better formulary management?

Greenleaf: One of the [most important] recent changes in MA plan formulary management has been with physician-administered Part B drugs. Back in 2018, CMS released guidance allowing MA plans to impose step therapy for these physician-administered drugs; [plans] could do this beginning in 2019, and they're still able to do that now and will continue to be going forward. There's been a lot of patient and provider pushback on this new ability to do step therapy for part B drugs.

When you think of Part B, physician-administered drugs, you think of cancer patients, rheumatoid arthritis—there’s some of the more complex and debilitating diseases. So, [there’s been] a lot of pushback from the provider and patient community. However, we have not seen CMS back down at all. Expect for [step therapy] to continue to be a new tool for plans to use now and going forward in Part B.

Another, more positive [development] from the biopharma manufacturer viewpoint, a more positive utilization management tool that plans have been using has to do with guideline adherence. The National Comprehensive Cancer Network and United Healthcare partnered up to do a study, [which] found that simply reminding physicians to adhere to specialty society guidelines could reduce total drug cost by 20%, which is obviously a huge reduction in costs. Guidelines are not new, but as you know, the debate around drug costs and controlling these costs continues. We expect that guideline adherence will continue to get more and more attention from plans.

AJMC^®: And, in fact, CMS has asked as part of the rate announcement for feedback on several specific issues related to the Part D program, including prior authorization. So, what do you expect the questions about this to involve in 2021?

Greenleaf: So, in the rate notice, CMS explained that they are working on a Medicare Advantage Star rating related to prior authorization. The Star rating measure will judge plans based on how well they're implementing prior authorization processes and how well a beneficiary is still able to get access to needed care, even when the prior authorization is in place. We think this is a great addition to the Medicare Advantage Star rating program.

In addition to working with biopharma manufacturers, I work with a lot of oncology practices and all these oncologists have so many horror stories—about being on the phone for hours with a health plan trying to get through the prior authorization process. Often the person they're speaking to on the other line is often not a physician, and if the person is a physician, they're often not an oncologist. So, prior authorization can cause some real headaches for both providers and patients. It's great to see that CMS is working on a Star rating measure. We'll be looking to see what that measure looks like.

Also, I think also going into 2021 and beyond when it comes to the Part D program specifically, we pay close attention to the Part D appeals process—the process by which if a beneficiary is faced with prior authorization or step therapy, or if the plan just simply denies coverage of a certain drug, I'm talking about that process that they can appeal those decisions currently. Thus far in the Part D program, this process has been very beneficiary friendly. By and large, for the vast majority of appeals beneficiaries usually went out and they're able to get access to the drug that that they want, so long as they're willing to tough it out through the appeals process. So, when we're talking about Part D access, that's an area we're closely watching; we’re looking to see if stakeholders asked for changes or if CMS signals they might make any changes to that process.

AJMC^®: I’m glad you brought up the oncologists, because we’ve heard from them, too. When the step therapy rules were first [published]. Do you think that this process—with the [opportunity for] feedback—will this give the oncologists a chance to tell some of their war stories and strike a little bit of a balance between the step therapy provision and what the oncologists are looking for?

Certainly, the oncology community has been very vocal [in] talking to CMS about some of the issues they're facing. I think they're going to continue to do that; CMS has been receptive. They just haven't gone so far as to formally reverse course on allowing for step therapy … we haven't gotten that far yet. But that dialogue is ongoing, and I think you'll continue to see the oncology community push for for changes there.

AJMC^®: You mentioned earlier, all the flexibility that CMS has given under Medicare Advantage, and it seems they're really encouraging enrollment in Medicare Advantage to be allowed. Plans [are allowed] to customize some of the services around chronic illness and some of the other conditions, [to provide] nutrition, all kinds of things that people may need. Should we expect more of these announcements?

Greenleaf: Certainly, to promote the Medicare Advantage plans and enrollment in general, yes. CMS has shown there they're trying to be as flexible as possible with MA plans. I think in today's environment with COVID-19, we've seen a flurry of activity coming from CMS giving health plans all sorts of new flexibilities. I think one of the biggest areas where we're seeing a lot of new flexibilities around telehealth. Now, throughout this COVID-19 pandemic, providers can get paid the same rate as a face-to-face visit, if they use telehealth with the patient, so long as there's an audio and video component involved. That's a huge change. That's something that digital health community has been asking for years, [but] they haven't gotten very far. This is a big shift, and it's an example of flexibilities that plans are given right now. And we expect for some of these flexibilities to continue after the pandemic is behind us, depending on how well this all plays out and providers and patients report favorably on these new telehealth flexibilities. So, yes, that's one area that CMS has already provided great flexibility and we expect it to continue.

AJMC^®: We're hearing the same thing—that people already love the telehealth provision and that once people get attached to it, it's probably not going to go away very easily. So, what do you think are the biggest tests ahead for Medicare Advantage in light of COVID-19?

Greenleaf: The biggest challenge for plans going forward is going to be [finding] that balance of providing COVID care while being able to implement traditional cost containment measures, like prior authorization. In this environment. it's really hard for plans to say no to anything right now. And that's, obviously going to have repercussions somewhere; it's going to end up being increased premiums. So, payers are going to be in a real bind. And this is what they're focusing on right now, and will continue to focus on the rest of the year: how they can best control these costs while still making sure that their members have access to the care they need?

AJMC^®: Well, Lindsay, thank you so much for joining us, and we'll have to talk to you again.