Unpacking Medicare Advantage Criticism With Dr Andrew S. Oseran

In part 1 of an interview with The American Journal of Managed Care^®, Andrew S. Oseran, MD, MBA, MSc, advanced heart failure and transplant cardiologist at Beth Israel Deaconess Medical Center, explains the criticism Medicare Advantage (MA) plans face from policy makers.

He also discusses the inspiration behind his study, "Prevalence of Chronic Medical Conditions Among Medicare Advantage and Traditional Medicare Beneficiaries."

This transcript has been lightly edited for clarity; captions were auto-generated.

Transcript

As mentioned in your study, MA plans have faced criticism from policy makers, particularly regarding payment structures. Can you explain some of their main concerns?

In contrast to traditional Medicare, which is paid on a fee-for-service basis, Medicare Advantage, or MA, plans are paid a fixed monthly capitated payment. Then, CMS, the federal government, adjusts these payments based on beneficiaries' underlying medical complexity.

The goal is to prevent plans from enrolling only healthy people, but you can imagine that this creates an incentive, specifically within the MA program, for plans to really aggressively code comorbid health conditions in order to receive higher payments from the government. By some estimates, this difference in coding intensity between MA, on the one hand, and fee-for-service Medicare, on the other hand, results in billions of dollars of excess cost to the federal government.

Policy makers are concerned that these payments may not all be clinically warranted and that plans may be gaming the system—or taking advantage of the system—to extract additional reimbursement. This was really the policy issue that motivated our study and this line of inquiry.

What was the objective of your study? Why did you decide to investigate this?

The primary objective of our study was to determine whether the prevalence of common chronic medical conditions is higher in MA compared with traditional Medicare beneficiaries. I know it seems like a relatively simple question, but it's really important that we get it right because if the MA population is indeed sicker, or is more complex, then perhaps some of the excess payments that we just discussed are appropriate and may even be necessary for plans to provide the care that these patients need.

Now, the issue is prior work has looked at this fundamental question, but a lot of the data that's used in those studies has had limitations. Some studies have used claims data to compare MA and fee-for-service populations, but those are going to be limited by differences in coding intensity that we just talked about. Other studies have used clinical registries to try to compare the 2 populations, but a lot of times, those registries are limited to narrow patient populations or populations with very specific chronic conditions, so the results are less generalizable.

In our study, we used the National Health and Nutrition Examination Survey, or NHANES, which is basically designed to monitor the health of the US population. The really unique thing about it is that, in addition to survey questions, it actually captures detailed physical examination and lab data on all its participants, which really circumvents a lot of the limitations of these other data sets that I discussed.

What we were able to do is we were able to link the NHANES survey with Medicare enrollment data through a DUA [data user agreement] with the National Center for Health Statistics, and we feel that this allows us to more accurately answer this fundamental question.