Addressing Serious Illness Care in Medicare Advantage

“we believe the quality bonus program (QBP), which offers incentives for providing high-quality care in Medicare Advantage, needs critical review and strengthening to improve accountability — steps that will be particularly important to support enrollees with serious illness. The foundation of the QBP is a five-star rating system in which plans are scored on the basis of claims-based performance measures and patient surveys. [..] A decade after the QBP’s implementation in 2012, however, concerns about its accuracy in measuring quality and its ability to drive quality improvement have been persistently documented in academic research and MedPAC reports.

The inaccurate reflection of quality in the current rating system hampers its ability to provide appropriate incentives for plan administrators and to guide consumers. Part of the problem is that the system assesses quality at the level of Medicare Advantage contracts, which are aggregations of local plans, not the level of individual plans. [..] Multiple plans are often aggregated into larger contracts, which are administered by commercial health insurers, such as Humana and UnitedHealthcare. As a result, a Medicare Advantage contract may contain various plans with distinct structures that are offered over noncontiguous regions and multiple states. Beneficiaries using the Plan Finder tool sponsored by the Centers for Medicare and Medicaid Services (CMS) may therefore lack the necessary information to assess a specific local plan. Despite CMS’s substantial investment in the QBP, there is no evidence that the program has improved the quality of care in Medicare Advantage.

Moreover, in at least two important ways, the QBP fails to adequately measure the quality of care delivered to enrollees with serious and complex illness. First, people with serious illnesses, such as dementia, are undersampled in Medicare Advantage Consumer Assessment of Healthcare Providers and Systems surveys, which inform quality ratings in the program. As a result, these ratings rely too heavily on the experience of people with no or stable medical illnesses and those who have fewer health care needs and less difficulty navigating the health care system than do people with serious illness. Second, many QBP measures, such as those related to disease prevention, may be less relevant to people with serious illness than to people without serious illness. There is less emphasis on indicators that are especially important to the experience of people with serious illness and their caregivers — for example, those capturing high-quality communication or care coordination. Although it may be challenging to improve the QBP by implementing reporting of plan-level data or data specific to people with serious illness, given the small number of such enrollees in some plans, CMS should ensure that quality measures provide consumers with actionable data for choosing a local health plan. Further research and creative solutions are needed to determine how best to accomplish this aim.

We believe several strategies could help address the concerns associated with current efforts to report on quality of care in Medicare Advantage. These challenges are complex, however, and multiple stakeholders will need to contribute to developing the best approaches to confronting them. Congress could commission a report from the National Academies of Sciences, Engineering, and Medicine on quality of care in Medicare Advantage, with a focus on people needing complex and high-cost care, particularly those with serious illness. The National Institutes of Health could prioritize research on a range of issues related to care delivery in Medicare Advantage that merit focused investigation, such as beneficiary experience and the best approaches to measuring quality of care for people with serious illness. More immediately, the Medicare Plan Finder website could provide clearer context for the plan data it presents (e.g., by listing the regions from which quality data are derived), and CMS could begin the process of improving quality measures to ensure that they are locally relevant and capture the experience of people with serious illness. CMS could also start publishing data on plan ownership and take steps to make encounter data more complete, as well as require accurate reporting on networks and the delivery of supplemental benefits. Substantial progress could be made by means of ongoing evaluations of the Medicare Advantage program by CMS contractors, especially if the methods and results of these evaluations were more transparent and subject to external review.”

Full editorial, CK Ankuda, MD Aldridge, RT Braun et al., New England Journal of Medicine, 2023.5.11