Currently Viewing:
The American Journal of Managed Care September 2019
VA Geriatric Scholars Program’s Impact on Prescribing Potentially Inappropriate Medications
Zachary Burningham, PhD; Wei Chen, PhD; Brian C. Sauer, PhD; Regina Richter Lagha, PhD; Jared Hansen, MStat; Tina Huynh, MPH, MHA; Shardool Patel, PharmD; Jianwei Leng, MStat; Ahmad Halwani, MD; and B. Josea Kramer, PhD
The Sociobehavioral Phenotype: Applying a Precision Medicine Framework to Social Determinants of Health
Ravi B. Parikh, MD, MPP; Sachin H. Jain, MD, MBA; and Amol S. Navathe, MD, PhD
From the Editorial Board: Jan E. Berger, MD, MJ
Jan E. Berger, MD, MJ
Medicaid Managed Care: Issues for Enrollees With Serious Mental Illness
Jean P. Hall, PhD; Tracey A. LaPierre, PhD; and Noelle K. Kurth, MS
Multi-Payer Advanced Primary Care Practice Demonstration on Quality of Care
Musetta Leung, PhD; Christopher Beadles, MD, PhD; Melissa Romaire, PhD; and Monika Gulledge, MPH; for the MAPCP Evaluation Team
Physician-Initiated Payment Reform: A New Path Toward Value
Suhas Gondi, BA; Timothy G. Ferris, MD, MPH; Kavita K. Patel, MD, MSHS; and Zirui Song, MD, PhD
Managed Care for Long-Stay Nursing Home Residents: An Evaluation of Institutional Special Needs Plans
Brian E. McGarry, PT, PhD; and David C. Grabowski, PhD
Changes in Ambulatory Utilization After Switching From Medicaid Fee-for-Service to Managed Care
Lisa M. Kern, MD, MPH; Mangala Rajan, MBA; Harold Alan Pincus, MD; Lawrence P. Casalino, MD, PhD; and Susan S. Stuard, MBA
Currently Reading
Did Medicare Advantage Payment Cuts Affect Beneficiary Access and Affordability?
Laura Skopec, MS; Joshua Aarons, BA; and Stephen Zuckerman, PhD
Which Patients Are Persistently High-Risk for Hospitalization?
Evelyn T. Chang, MD, MSHS; Rebecca Piegari, MS; Edwin S. Wong, PhD; Ann-Marie Rosland, MD, MS; Stephan D. Fihn, MD, MPH; Sandeep Vijan, MD; and Jean Yoon, PhD, MHS
Call Center Performance Affects Patient Perceptions of Access and Satisfaction
Kevin N. Griffith, MPA; Donglin Li, MPH; Michael L. Davies, MD; Steven D. Pizer, PhD; and Julia C. Prentice, PhD

Did Medicare Advantage Payment Cuts Affect Beneficiary Access and Affordability?

Laura Skopec, MS; Joshua Aarons, BA; and Stephen Zuckerman, PhD
The Affordable Care Act’s reductions to Medicare Advantage plan payments were not significantly associated with healthcare access or affordability for enrollees.
ABSTRACT

Objectives: To explore whether the Affordable Care Act (ACA)’s Medicare Advantage (MA) payment cuts were associated with changes in enrollees’ access to and affordability of healthcare relative to traditional Medicare (TM).

Study Design: Descriptive analyses of changes in access and affordability in MA relative to TM between 2009 and 2017 and between 2011 and 2017.

Methods: Respondents who reported Medicare coverage on the National Health Interview Survey were divided into MA and TM enrollees. Using multivariate regression to adjust for demographic, economic, and health status changes over time, we compared changes in healthcare access and affordability for the 2 groups between 2009 and 2017, as the ACA payment cuts were implemented. For some measures, the analysis covers 2011 to 2017.

Results: Between 2009 and 2017, MA respondents did not report statistically significant changes in healthcare access or affordability after adjusting for demographic, socioeconomic, and health status changes in the MA population. There were no statistically significant differences between changes in access and affordability for beneficiaries in MA relative to those in TM over this period.

Conclusions: Although MA payment cuts were expected to reduce the attractiveness of the MA program to both plans and enrollees, the program’s enrollment grew steadily from 2009 to 2017. Over this period, plans reduced their costs for providing Part A and Part B benefits to their enrollees, thereby preserving room for rebates. Our findings show that plans made such cost reductions without significantly affecting enrollees’ access to or affordability of care compared with TM beneficiaries.

Am J Manag Care. 2019;25(9):e261-e266
Takeaway Points
  • The Affordable Care Act’s reductions to Medicare Advantage (MA) plan payments did not significantly affect healthcare access or affordability for enrollees.
  • Although MA enrollment was predicted to fall due to payment reductions, it increased instead.
  • MA plans decreased their bids while managing to preserve or improve their attractiveness to beneficiaries, possibly by keeping premiums, extra benefits, and access and affordability relatively stable.
Prior to the Affordable Care Act (ACA), Medicare Advantage (MA) plans were overpaid,1-3 costing the Medicare program an average of 114% of traditional Medicare (TM) spending per beneficiary nationally in 2009.4 The ACA reduced payments to MA plans through changes to the MA benchmark-and-bidding system, resulting in MA plans, on average, costing 100% of TM spending per beneficiary nationally in 2017.5 Research suggests that MA plans were able to reduce their costs and maintain extra benefits under this payment pressure.1,6 However, less is known about how plan responses to changes to MA payments under the ACA may have affected beneficiaries’ access to and affordability of care and whether MA plan cost reductions may have come at the expense of beneficiaries through narrower networks, stronger utilization management, or higher cost sharing. Using data from the 2009, 2011, and 2017 rounds of the National Health Interview Survey (NHIS), we assessed whether reductions in MA plan payments affected enrollees’ healthcare access and affordability relative to TM beneficiaries over this period.

Background on MA Program

The MA program allows Medicare beneficiaries to receive their Part A and Part B benefits through private plans. To participate in the program, private plans submit a bid to CMS equal to the expected cost, including administrative costs and profits, of providing Medicare Part A and Part B benefits to an average-risk Medicare enrollee. This bid is compared with a predetermined benchmark set by CMS. Plans bidding below the benchmark receive a portion of the difference between the benchmark and their bid as a rebate, which must be used to provide extra benefits, such as lower cost sharing, to enrollees. The availability of extra benefits at no additional cost to enrollees has been thought to be an important driver of MA enrollment.7-9

Impact of the ACA

The ACA made significant changes to the process for calculating benchmarks and rebates, generally lowering them to bring average payments to MA plans more in line with TM spending per beneficiary. Under the ACA, benchmarks are based on average TM spending per beneficiary in a county, with some variation across counties to preserve choice and reward plans with high quality ratings. Additionally, the ACA lowered the share of the difference between benchmarks and bids that plans would receive as a rebate from 75% to between 50% and 70%, depending on the plan’s quality rating. Nationally, the ACA lowered benchmarks from an average of 118% of TM spending per beneficiary in 2009 to an average of 106% in 2017.4,5 In turn, MA plans lowered their bids from 102% of TM spending per beneficiary in 2009 to 90% in 2017.4,5 This preserved space for rebates,6 which fell only from 12% of TM spending per beneficiary in 2009 to 10% in 2017.4,5

The reduction in MA bids relative to TM from 2009 to 2017 could reflect changes in MA plan structure that would negatively affect beneficiaries’ access to care and affordability of care, such as increased utilization management, higher cost sharing, or narrower networks. In addition, the rebate reductions over this period could have harmed beneficiaries through higher cost sharing, although these reductions were small on average. This study sought to explore whether plan responses to the ACA’s payment reductions to MA plans were accompanied by changes in MA beneficiaries’ access to and affordability of care relative to TM beneficiaries.

METHODS

Data Sources

Our data are from the NHIS, which is a nationally representative household survey conducted by the US Census Bureau.7 The survey collects information from approximately 87,500 noninstitutionalized residents across 35,000 households each year. All respondents provide health insurance coverage and healthcare affordability information for all household members, but only 1 adult per household is sampled for access-to-care questions. Following the passage of the ACA, the NHIS added several questions on access to and affordability of care in 2011.

We focused primarily on data from the 2009 and 2017 rounds of the survey to allow us to best compare access and affordability pre- and post ACA payment changes. We also compared 2011 and 2017 NHIS data to allow us to use the additional questions on access to and affordability of care added to the NHIS in 2011. As the ACA’s payment cuts were first implemented in 2011 and would not affect enrollees until the 2012 plan year, we were still able to compare access and affordability pre- and post ACA. We opted to use the 2009 and 2017 surveys for our primary analysis, as the passage of the ACA froze payments at 2009 levels during early implementation, potentially affecting the MA market.


 
Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up