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Donald Berwick, MD and Rick Gilfillan, MD. On September 30, 2021, it’s been almost a year since they launched a frontal attack on Medicare Advantage (MA) on their blog. Health issues Online “Medicare Benefit, Direct Contracting, and the Medicare ‘Money Machine.'” That blog was the second in a two-part series of blogs, but it got almost all of the public’s attention and, of course, sparked a firestorm in federal health care policy circles.
As reported in the news that dayDr. Berwick, who served as Acting Administrator of the Centers for Medicare and Medicaid Services (CMS) from July 2010 to December 2011, and Dr. Gilfillan, who served as Deputy Administrator and Director of the Centers for Medicare and Medicaid Services from 2010 to 2013, led the Center for Medicare and Medicaid Innovation, “The New Under Medicare He criticized the direct contracting program, ongoing changes to the Medicare Advantage program, and some of the major issues facing accountable care organizations. (ACOs) are managed under the Medicare Shared Savings Program (MSSP). They assert that any financial incentive is fundamentally wrong and undermines the Medicare program and true cost-based contracts.
Several industry leaders jumped in to make their point, including then-president and CEO Don Crane. APG, American Physicians Group, an association that represents many of the most advanced multi-specialty physician groups in the country. As reported last September 30, “APG Crane wrote in a letter to HHS Secretary Becerra on Thursday that, “In their materials, Dr. Berwick and Gilfillan CMS of HCC. They proposed to replace the RAF. [risk adjustment factor] Within two years, begin a process to develop an outcome process and an approach that is not based on vendor reporting. They claim this is important because of the significant MA “overpayment” of risk-adjusted code inflation. Risk adjustment,” Crain emphasized, “is designed to estimate the beneficiary’s future health care costs and adjust reimbursement to the severity of the disease and related medical costs as complex patients require additional resources. Risk adjustment encourages enrollment of sicker patients and those of lower socioeconomic status and is widely used by MA and the Medicare Shared Savings Program (MSSP) to fine-tune quality, cost, and cost measures, making them more accurate. Performance measurement. Alignment of payment and performance goals rewards coordinated care and promotes improved health and care outcomes among all individuals.
Fast forward to the summer of this year and last month, another group of policy leaders jumped into the conversation. In their comments on July 8 Health issues Online, title “Doing the Right Investigation: A Reply to Berwick and Gilfillan.” Jeffrey Kang, MD, MPH, Ian Duncan, Ph.D.And Nhan Huynh, Ph.D.Berwick and Gilfillan walk their readers through a series of complicated propositions, concluding that in their view they have completely missed the point. As they write, “The ongoing debate over the merits or demerits of MA has diverted attention from the main problem, the relatively high fees in MA and TM.” [traditional Medicare] And their reasons and thus fail to provide a meaningful solution. MA plans compete with TM on a level playing field if relatively high fees remain, the original congressional intent of the two programs. We therefore respond to the coding and risk adjustment issues raised in Berwick and Gilfillan’s original posts, focusing specifically on the root cause of higher premiums, the rationale for disease-based risk adjustment, and the solution.
Indeed, these experts wrote, “We agree that there is evidence for higher payments for MA plans relative to TM. What is unclear is whether this is due to the problem of over-coding in MA or the problem of coding obfuscation in TM. The incentive in MA is for physicians to give general codes for diagnoses.” is (International Classification of Diseases (ICD) codes, specifically ICD-10 codes); the incentive in TM is for physicians to code procedures (using Current Procedural Terminology (CPT) codes).
These authors have significant evidence to bring to the discussion. According to the article, Jeffrey Kang, MD, MPH, chief medical officer at the Centers for Medicare and Medicaid Services (then the Health Care Financing Administration) developed a disease-based risk adjustment model, Hierarchical Condition Categories (HCC). He is currently the CEO of Welbe Senior Medical, a home-based geriatric group that cares for frail, needy, complex Medicare beneficiaries. Ian Duncan, Ph.D., FSA FIA FCIA FCA CSPA MAAA, Assistant Professor of Actuarial Statistics at the University of California, Santa Barbara, and Santa Barbara Actuaries Inc., a provider of healthcare predictive modeling and actuarial services. He is the president. Dr Duncan holds a postgraduate degree in Economics from Balliol College, Oxford and a PhD. in Statistics from Heriot-Watt University, Edinburgh, Scotland. He is a partner of many concrete societies. He is active in public policy and health care reform and served on the Board of Directors of the Commonwealth of Massachusetts Health Insurance Liaison Authority from 2007-2014. He was also a board member of the Society of Actuaries (2012-5) and currently chairs the SOA Research Executive. and Nhan Huynh, Ph.D., is a consultant at Santa Barbara Actuaries Inc.”
Kang, Duncan, and Huynh write that “an important goal of disease-based risk-adjustment is to accurately pay members’ “disease burden” MA plans.” Instead of abandoning disease-based risk adjustment, policymakers should address the incentives associated with coding. The correct short-term solution is to adjust the relatively high coding intensity with MA. In the medium term, instead of abandoning disease-based risk adjustment in MA, CMS should introduce disease-based risk adjustment in TM. This not only (a) differentiates coding between MA and TM, but (b) also provides appropriate guidance to providers caring for patients with TM. Then, eventually, once the two programs are on equal footing (ie, with similar incentives to adopt diagnostic codes), it may be appropriate to modify risk adjustments in both programs to account for patient differences, they write. For example, both in practice and in social issues of health (SDOH).
The authors directly address Berwick and Gilfillan’s argument that Medicare Advantage encourages diagnostic coding, with the implication that proper diagnosis coding occurs in traditional Medicare. However, as Kang, Duncan, and Huynh note, traditional Medicare clearly pays based on work units rather than patient complexity, a fact that inherently encourages bias. They write, “For example, take a patient with three chronic conditions: CHF [congestive heart failure], diabetes with nephropathy and peripheral vascular disease. Let’s say the patient is seen three times a year. In MA, this patient would have all three diagnoses coded over three visits, but the same CPT code would be used for two intermediate and one short visit for all three visits. Conversely, the same patient in TM would have one general and two intermediate visits coded but only a diabetes diagnosis was provided. In MA, the physician has an incentive to capture all three diagnoses, including complications (nephropathic diabetes draws a higher HCC score than diabetes itself). In TM, the doctor is billed according to the CPT code, regardless of the diagnosis. Therefore, the same patient diagnosis codes are more likely to be overcoded by TM and MA.
After walking readers through the complexities of comparing incentives in Medicare Advantage and traditional Medicare, the authors write: “In the short term, it returns us to a world of disease-based risk adjustment rather than abandonment.” As MA plans are incentivized to “hit the healthy” and plans with bad choice experiences are underpaid, we believe that CMS will continue to use the tools it has in place to address code strength issues and go to physician-reported conflict data. ” And, “In the medium term, instead of abandoning the MA disease-based risk adjustment approach, CMS should continue the path marked by the CMS Innovation Center by using disease-based risk adjustment approaches in Medicare FFS. We can imagine a world where physicians are either in FFS or managed care or both. All physicians will have incentives to accurately and completely prescribe the diagnosis, and then pay a fee appropriate to the care of all complex patient conditions and the patient’s disease burden.
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