Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244
RE: Medicare Program; Request for Information on Medicare Advantage Data
Dear Administrator Brooks-LaSure:
The National Health Council (NHC) appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) in response to the Medicare Program; Request for Information on Medicare Advantage Data (MA data RFI).
Created by and for patient organizations over 100 years ago, the NHC brings diverse organizations together to forge consensus and drive patient-centered health policy. We promote increased access to affordable, high-value, equitable, and sustainable health care. Made up of more than 170 national health-related organizations and businesses, the NHC’s core membership includes the nation’s leading patient organizations. Other members include health-related associations and nonprofit organizations including the provider, research, and family caregiver communities; and businesses and organizations representing biopharmaceuticals, devices, diagnostics, generics, and payers.
Overarching Comments
The significant growth of Medicare Advantage (MA) in recent years highlights the timeliness of this RFI. As of 2023, 30.8 million individuals, representing 51 percent of Medicare beneficiaries, are enrolled in MA plans, a substantial increase from 31 percent less than a decade ago.1
This trend underscores the importance of informed decision-making for those with chronic diseases and disabilities, who face crucial choices regarding their health care coverage – whether selecting between traditional Medicare and MA, choosing among MA plans, or navigating their selected plan to access necessary care. For people with chronic diseases and disabilities, the stakes for these decisions can be extremely high, and it is critical they have access to the information they need to make informed decisions. The NHC has consistently advocated for the active involvement of patients and their families in decisions that affect their health care. We believe in the power of high-quality patient engagement that is characterized by sustained, reciprocal communication between patients and decision- makers.
We also believe that transparency is paramount to assuring patients are able to make informed decisions. This requires consistency and accuracy of data, which makes this RFI important. As part of CMS’ process, we recommend establishment of an engagement framework that transcends traditional consultation, facilitating a continuous exchange of information. This approach should address queries such as those posed in this RFI, among others, providing CMS with timely insights directly from those most impacted by its policies. Moreover, we urge CMS to collaborate with patient advocates and health care plans to create guidelines for integrating patient perspectives into plan design and operational decisions. For instance, CMS could guide plans on setting up consumer advisory groups that include individuals with chronic conditions and disabilities. These groups would serve as a platform for ongoing input on various aspects of plan operation, from design to quality assessment. The NHC is ready to support CMS in shaping these engagement strategies, drawing upon our extensive experience and toolkit developed over the years for effective patient involvement.2 Patient organizations, often the first point of contact for individuals seeking guidance on navigating the Medicare system, possess invaluable insights into the program’s strengths and shortcomings from the patient’s viewpoint. Leveraging these organizations as partners in establishing a robust patient engagement feedback loop is essential. Through such collaborative efforts, we can ensure that the Medicare system, particularly the MA program, is responsive to the needs and experiences of all beneficiaries, particularly those with chronic illnesses and disabilities.
Health Equity
Health equity is foundational to ensuring high-quality care in the MA program. While existing tools like the Health Equity Index serve to measure disparities, the NHC believes that a more nuanced and comprehensive approach is necessary to capture the full spectrum of factors influencing health equity. To this end, the NHC urges CMS to adopt measures that go beyond current practices by integrating a broader array of social determinants of health (SDOH) data into MA plan assessments. This would include variables such as socioeconomic status, geography, language, and disability status, which are pivotal in understanding and addressing the barriers to equitable care.
Furthermore, we recommend that CMS leverages the newly released Statistical Policy Directive No. 15 to enhance the granularity of race and ethnicity data collection as quickly as possible.3 By doing so, CMS can identify and address health disparities in more specific and effective ways. Moreover, incorporating these detailed health equity metrics into the overall quality measurement and improvement frameworks used to evaluate MA plans will ensure a holistic view of plan performance, not limited to clinical outcomes but extending to equitable care delivery. Such metrics could include patient satisfaction scores disaggregated by detailed demographic categories, alongside analyses of treatment outcomes by population group.
By enriching the data framework and embedding comprehensive health equity measures into the evaluation process, CMS can ensure that all beneficiaries receive care that is not only clinically effective but also equitable and respectful of their diverse needs. This enhanced approach will not only improve individual health outcomes but also strengthen the systemic health of the entire MA program, fostering a more inclusive health care environment.
Beneficiary Engagement
The NHC emphasizes the crucial role of beneficiary engagement in enhancing the effectiveness and responsiveness of MA plans. CMS should require plans to establish a comprehensive engagement framework that mandates ongoing interaction between MA plans and beneficiaries. CMS should require MA plans to implement and maintain platforms for continuous feedback, using the insights gathered to assess the effectiveness of engagement strategies and improve communication.
To this end, the NHC recommends that CMS collaborate with MA plans to:
Integrate patient perspectives into their design and operations, particularly by establishing and maintaining consumer advisory groups that include a diverse range of beneficiaries. CMS should recommend annual reporting from MA plans on how these integrations affect plan utilization, satisfaction, and health outcomes, ensuring accountability and continuous improvement.
Involve beneficiaries in the initial creation and ongoing refinement of marketing materials and material templates, ensuring that these materials meet both regulatory standards and beneficiary CMS should encourage MA plans to systematically collect and analyze beneficiary feedback on these materials, utilizing this data to continuously enhance the materials. This approach ensures that marketing efforts are effectively aligned with the informational needs and decision-making processes of beneficiaries, fostering a cooperative environment that supports informed choices. and improve the templates to ensure that marketing efforts are effectively aligned with the informational needs of beneficiaries.
Utilize beneficiary feedback, including patient-reported outcomes (PROs), to inform quality measurement and improvement initiatives within MA plans. CMS should require plans to incorporate this feedback into their quality improvement strategies, providing clear guidelines on how to effectively gather and use this information.
Actively involve beneficiaries in the design and continual refinement of services. CMS should evaluate the impact of beneficiary involvement on plan performance and satisfaction, facilitating a competitive environment that prioritizes patient needs and preferences.
Addressing the Needs of Special Populations within the MA Program
The NHC recognizes that ensuring equitable access to health care services and improving health outcomes for all beneficiaries within the MA program requires addressing the diverse needs of special populations. Special populations include, but are not limited to, individuals dually eligible for Medicare and Medicaid, individuals who qualify for Medicare not through age but due to a disability, such as those with end-stage renal disease (ESRD) or diagnosed with amyotrophic lateral sclerosis (ALS), and beneficiaries with complex health conditions. These groups face unique challenges that necessitate tailored care approaches and enhanced support mechanisms. The Medicare population is heterogenous, and a one- size-fits-all solution does not adequately address the varied needs of these groups. For instance, individuals dually eligible for Medicare and Medicaid may navigate complex health and social service systems, while people with ALS require the coordination of multidisciplinary services and complex medical equipment and those with ESRD require specialized renal care services that integrate multiple aspects of treatment and support. To ensure that interventions and care models are effectively meeting the needs of these diverse groups, the NHC calls for comprehensive and ongoing research and data collection efforts. This includes studying the effectiveness of various interventions and care models tailored to the specific challenges faced by these populations. CMS should facilitate and fund research initiatives aimed at identifying best practices for serving special populations, with the goal of scaling successful approaches across the MA program. Through targeted research, continuous data collection, and the adaptation of care models to meet specific needs, CMS can ensure that all beneficiaries receive high-quality, equitable care tailored to their individual circumstances.
Building on these overarching considerations, the NHC provides the following responses to the specific areas of interest identified by CMS in this RFI to inform CMS’ efforts in enhancing data collection and release for MA organizations.
Specific Data-Related Recommendations
Beneficiary Access to Care
The NHC underscores the critical need for comprehensive and up-to-date provider directories to guarantee beneficiary access to care within MA plans. NHC members have expressed significant concerns regarding network adequacy, which can significantly impact patient choices and access to needed specialists. To increase patient choice the NHC recognizes the importance of ensuring the accuracy of provider availability by maintaining up-to-date provider directories. Providers are responsible for promptly updating any changes in their service details and responding to health plan inquiries. Equally, MA plans and CMS must create conditions that simplify these updates for providers, ensuring that the process is as straightforward as possible to encourage timely reporting. This includes regular updates to provider directories and enforcing accuracy through mechanisms such as secret shopper surveys.
To support these efforts, the NHC recommends that CMS implement regulations that not only mandate these updates but also streamline the processes involved, making it easier for plans and providers to comply. This could be further enhanced by the development of a National Directory of Healthcare Providers and Services, a centralized resource that could significantly enhance the reliability of provider information. The NHC previously contributed ideas to this initiative, providing recommendations in our response to CMS’ request for information on this subject.4,5 NHC seeks updates on CMS’ progress in developing this directory, which would be a critical step towards ensuring beneficiaries receive accurate and reliable information crucial for making informed health care decisions.
Additionally, the NHC recommends that CMS establish and enforce clear, standardized requirements for MA plans regarding prior authorization and utilization management (UM) practices. Such practices, as currently implemented, can act as barriers to care, delaying or denying necessary treatments for beneficiaries.6,7,8,9,10,11 While we support CMS’ proposal to require payers to report certain prior authorization metrics, such as the list of all items and services that need prior authorization, the percentage of standard and expedited requests that were approved, denied, or approved after appeal, the average and median time between request submission and a decision, we also recognize the importance of evaluating the effectiveness of existing data collection efforts. Given the data collection and reporting requirements already in place or planned, the NHC urges CMS to conduct a thorough evaluation of current transparency efforts related to prior authorization data to assess their impact and effectiveness. This evaluation should inform what additional data collection and reporting requirements are needed. We agree with CMS that increasing transparency in these processes will aid beneficiaries in comparing different health plans and ensure that plans are adhering to CMS’s nondiscrimination policies, including those aimed at aligning benefits between MA and traditional Medicare. Based on the findings of this evaluation, CMS should consider implementing new data collection and reporting requirements to address identified gaps. This approach will ensure that enhancements to data collection and reporting are both justified and targeted, addressing specific needs that are not currently met by existing practices. Such measures will help identify plans that excessively use these practices in a manner that restricts access to care, thereby triggering targeted oversight or corrective actions.
To further understand the full impact of these practices, the NHC suggests that CMS conduct or contract for a comprehensive study to assess the costs and benefits associated with UM, including non-quantifiable effects such as beneficiary anxiety and suffering due to delayed or forgone care. This study would provide critical insights into how UM practices affect patient health outcomes and overall well-being, enabling more informed policy decisions.
Moreover, CMS should enhance transparency by requiring MA plans to make their criteria for prior authorization and UM publicly available, allowing patients and providers to better understand and navigate these processes. The NHC applauds the advancements made in the recent interoperability final rule, which aims to streamline prior authorization processes and improve data exchange across health care systems.12 However, we note that while the rule enhances data sharing capabilities, it does not apply directly to prescription drugs, a significant component of health care for many beneficiaries. The NHC urges CMS to extend the benefits of interoperability to include comprehensive medication information, thereby reducing delays and improving transparency in medication management. This expansion is crucial for ensuring that MA beneficiaries have complete access to the care they need, including timely and appropriate medication therapies.
In light of the Inflation Reduction Act (IRA) of 2022 and the subsequent changes to the Medicare Part D benefit structure, the NHC has expressed concerns regarding potential unintended consequences that may arise, particularly as they pertain to formulary decisions affecting patient access to essential medications.13,14,15 With plans taking on increased financial liability, there is a risk that changing incentives could lead plans to impose narrower formulary access, impacting the most vulnerable patient populations. To mitigate these concerns, the NHC proposes intensified collection and transparency of data on formulary inclusiveness to ensure that necessary medications remain accessible without imposing undue restrictions or high out-of-pocket (OOP) costs on patients.
Supplemental Benefits
The NHC supports the incorporation and targeted expansion of supplemental benefits within MA plans, understanding their pivotal role in holistically addressing the health needs of beneficiaries, particularly through mitigating SDOH.16 Recognizing the profound impact of non-medical factors such as housing stability, nutritional access, and transportation on health outcomes, the NHC emphasizes the need to broaden the scope of these benefits without compromising the core benefits provided under Medicare.17,18 These non-medical factors often serve as the root causes of health disparities, affecting individual’s’ ability to manage chronic conditions, access essential medical care, and maintain overall wellness.19 Furthermore, the NHC encourages CMS to ensure that supplemental benefits are effectively supporting all MA participants, particularly those with chronic diseases and disabilities. It is essential to engage patients in discussions about the design and implementation of these benefits to ensure they meet the real-world needs of those most affected. With the recent implementation of CMS’ expanded reporting framework, new data on the utilization of supplemental benefits is now available. This development provides an invaluable resource for evaluating how these benefits are deployed across different demographic groups. The NHC recommends that CMS thoroughly evaluate this newly available data to understand the usage and impact of supplemental benefits. This evaluation should focus on identifying disparities in access and utilization across various demographic groups, including race, ethnicity, income level, disability status, and ZIP code. Such analysis is crucial for determining whether the current offerings meet the diverse needs of all beneficiaries and for guiding any necessary adjustments to ensure equitable access to these important benefits. As this new data becomes available, it will be instrumental in shaping strategies that not only enhance the scope of these benefits but also ensure they do not compromise the core benefits provided under Medicare.
MA Marketing Activities
The NHC acknowledges the crucial role of marketing in informing MA beneficiaries about their health care options. We recognize that effective marketing strategies are essential for ensuring that beneficiaries are well-informed about the range of available MA plans and can make decisions that best suit their health care needs. Given the importance of clear communication, it is vital that marketing materials are accessible and easily understood, particularly for beneficiaries with cognitive challenges and/or limited health literacy, who may find navigating the complex information presented during the open enrollment period overwhelming. The NHC urges CMS to engage collaboratively with MA plans to track the clarity, accuracy, and transparency of marketing materials and communications. This may include the need for CMS to monitor what information is being provided, how messages were developed with patient engagement, where it is being seen, and what impact it has on plan choice. These are all data sets that CMS can and should track and make transparent.
To support this collaborative approach, the NHC suggests several key strategies. Firstly, we recommend the establishment of comprehensive guidelines by CMS, developed in partnership with MA plans and informed by beneficiary engagement, to ensure marketing materials are easily understandable and accurately represent plan offerings. This includes the use of plain language, alternative languages, and clear explanations that can be easily navigated by all beneficiaries. Secondly, the NHC sees value in ongoing dialogue and cooperation between CMS and MA plans to continuously monitor and review marketing practices. This cooperative approach should aim to promptly identify and address any areas for improvement, ensuring marketing practices align with the goal of informed beneficiary decision-making. Thirdly, the NHC supports the development of educational resources that empower beneficiaries to navigate MA plan options effectively. These resources could include guidelines on what questions to ask and key factors to consider, helping beneficiaries to evaluate how different plans meet their health care needs.
Additionally, the NHC suggests that CMS ensure that MA plans provide CMS and beneficiaries with information to effectively compare plan features directly against other available options, including Original Medicare. Comparison tools, whether created by MA plans or CMS, should be designed to help beneficiaries assess plans based on their individual health care requirements and financial considerations, with MA plans required to supply accurate and comprehensive information to support these tools. To further enhance understanding and informed decision-making, the NHC recommends that CMS make these comparison tools readily accessible to patient organizations, enabling them to better educate their communities about the options and intricacies of MA plans.
Care Quality and Outcomes
The NHC is deeply committed to enhancing care quality and health outcomes within the MA program. Recognizing the significance of these factors in the overall well-being of beneficiaries, the NHC supports a multifaceted approach to improve and measure care quality, emphasizing the incorporation of value-based care models, patient-reported outcomes (PROs), and health equity measures.
PROs are critical in assessing the effectiveness of health care from the patient’s perspective.20 While PROs capture the patient’s voice regarding their symptoms, quality of life, and treatment satisfaction, it is essential to recognize that not all PROs are automatically patient-informed or patient-centered.21 To ensure that PROs truly reflect the patient’s experience and perspective, the NHC recommends that CMS develop guidelines to ensure that PRO measures are both relevant and meaningful to patients. This involves engaging with patients in the development of PRO measures and continually validating these measures to confirm they accurately capture meaningful aspects of patient experience. The NHC suggests that CMS consider including these validated, patient- centered PRO measures in MA plan performance evaluations. This integration would ensure that these important indicators of care quality are consistently captured and used to inform care improvement efforts.
Building on the foundation of patient-centered feedback, the development of regulatory frameworks that promote value-based care models that reward health care providers based on patient outcomes – rather than the volume of services provided – is crucial. These models should be backed by incentives aligned with data that demonstrate their effectiveness in improving health outcomes and reducing costs, incorporating metrics like patient satisfaction and health improvements. Regular reviews of such data are essential, as they allow CMS to adjust incentives to meet the evolving needs of beneficiaries, fostering ongoing innovation and improvements across the MA market.
To underscore the importance of these efforts, it is noteworthy that in 2022, over half (57%) of health care payments from MA plans were tied to value-based care models through alternative payment models (APMs), compared to 41% in traditional fee-for-service Medicare.22 This demonstrates significant progress in the shift towards value-based care within MA and highlights the potential for further advancements through comprehensive support and strategic guidance from CMS.
To effectively support this transformation towards high-quality health care, the NHC recommends that CMS guide MA plans in developing and implementing robust value-based care models that prioritize patient outcomes and cost efficiency, aligning closely with the principles of patient-centered care. Ensuring that health care delivery not only meets clinical standards but also enhances patient satisfaction and manages costs effectively is essential. A platform for the exchange of successful strategies and best practices 23 among plans can accelerate the adoption of proven practices that enhance patient care and promote cost efficiency.
Finally, the NHC emphasizes the importance of transparency in care quality and outcomes reporting. We urge CMS to require MA plans to publicly report detailed quality metrics, including outcomes data, value-based care model performance, and health equity indicators. Making this information publicly available will empower beneficiaries to make informed health care choices and stimulate competition among plans to improve care quality.
Market Competition
Healthy competition with the MA program is widely recognized as beneficial for enhancing the quality and affordability of health care services for beneficiaries. It encourages MA plans to innovate and strive for excellence, ensuring that beneficiaries have access to a range of high-quality options. The NHC acknowledges the importance of fostering an environment where competitive dynamics lead to better service delivery, improved health care outcomes, and more efficient use of resources. CMS’ role in regulating and facilitating market conditions that support fair and beneficial competition is vital for the well-being of all beneficiaries. Robust data collection and analysis are crucial in helping CMS gain valuable insights into the dynamics of competition, identify potential areas for regulatory improvement, and implement policies that foster a healthy competitive environment.
Providing clear, accessible information on plan performance, pricing, and beneficiary satisfaction is crucial for helping beneficiaries make informed decisions. Ensuring that this information is readily available and understandable empowers beneficiaries to make choices based on quality and value, rather than cost alone, fostering a competitive landscape that prioritizes beneficiary satisfaction and health outcomes.
This type of transparency also supports the integrity of the MA market by promoting an environment where all plans have the opportunity to demonstrate their value based on transparent and consistent criteria, encouraging them to continuously enhance their offerings.
Medicare Advantage Prescription Drug Plans (MAPDs)
Medicare Advantage Prescription Drug Plans (MAPDs) integrate prescription drug coverage, presenting unique challenges and opportunities for improving health care delivery. The NHC emphasizes the critical need for seamless coordination between pharmacy benefits and medical coverage to optimize treatment outcomes and enhance patient care. To achieve this, we recommend that CMS mandate clear, accessible information on formulary changes, coverage criteria, and out-of-pocket costs to ensure beneficiaries are well-informed and can manage their health effectively.
Further, strong data collection on formulary review processes is crucial to ensure that MAPDs offer a comprehensive range of essential medications, including access to the latest therapies as they become available. These processes should align with the latest clinical guidelines and be transparent to both providers and beneficiaries, enabling better decision- making and adherence to prescribed therapies. Given the significant impact of pharmaceuticals on patient health, particularly for those managing chronic conditions, CMS should also promote best practices among MAPDs that facilitate enhanced communication and data sharing between health care providers and pharmacists. This integration is vital for preventing adverse drug interactions and ensuring that medication management strategies are as effective as possible.
Moreover, the NHC reiterates concerns regarding the growth of UM practices within MAPDs, particularly for drugs, which have historically received less oversight compared to UM for other services and items. These practices, often serving as barriers to timely access to necessary treatments, should be rigorously evaluated and regulated by CMS to prevent undue delays or denials of care. We urge CMS to require MAPDs to report detailed data on prior authorization and UM practices specifically for medicines, including approval and denial rates and timeliness of decision making. This transparency will allow for targeted oversight and necessary corrective actions, ensuring that UM practices are clinically based as well as fair, efficient, and patient-centered.
Lastly, we recognize the potential for MAPDs to contribute significantly to the advancement of value-based care within the MA program. By incentivizing medication use that is aligned with improved health outcomes, CMS can foster an environment that rewards quality and efficiency in pharmaceutical care. Regular reviews and updates to the incentives for MAPDs that successfully implement these models will be crucial for encouraging ongoing innovation and quality improvements.
Geographic Impacts
The NHC emphasizes the importance of data collection and research to better understand and address the geographic disparities in health care access and outcomes within the MA program. CMS should invest in research initiatives and data analytics to identify gaps in service delivery, monitor the effectiveness of interventions aimed at reducing geographic disparities, and adapt strategies based on evidence-based findings.
Addressing geographic impacts within the MA program is critical to ensuring equitable access to health care services for beneficiaries across diverse regions. The NHC recognizes that beneficiaries in rural and underserved urban areas face unique challenges, including limited health care provider networks, scarcity of specialty care, logistical barriers to accessing health care services, and environmental and social factors negatively impacting their health. To mitigate these challenges and promote health equity, the NHC advocates for several strategic initiatives aimed at enhancing health care delivery and access in geographically diverse settings.
Firstly, the NHC recognizes that CMS already collects extensive data on provider networks within MA plans, particularly in rural and underserved urban areas. To make effective use of this data, the NHC recommends that CMS initiate a detailed analysis to evaluate the current state of these networks. This analysis should focus on examining changes in beneficiary access metrics, patient satisfaction, and health outcomes to thoroughly assess the existing needs and identify gaps in service provisions. With insights derived from this analysis, the NHC then urges CMS to develop targeted incentives to encourage health care providers to join MA networks in these regions and to develop innovative partnerships with community health centers, rural health clinics, and telehealth providers. By basing the expansion and enhancement of provider networks on a comprehensive analysis of existing data, CMS can ensure that interventions are precisely tailored to improve timely access to primary care and specialty services for all beneficiaries, enhancing equity and efficiency across diverse geographic areas.
Secondly, telehealth has emerged as a critical tool for overcoming geographic barriers to health care access. The NHC recommends that CMS continue to support and expand telehealth services within the MA program, including covering a broader range of telehealth- delivered services and removing any remaining regulatory barriers that limit the use of telehealth. Recognizing that the Medicare Payment Advisory Commission (MedPAC) has conducted analyses on telehealth’s impact on health service utilization and outcomes, the NHC suggests that CMS should build on this existing data to continuously monitor and evaluate the effectiveness of telehealth services.24 Ongoing analysis is essential to understand the evolving impact of telehealth, particularly in how it can be further optimized to improve access to preventive services, chronic disease management, and specialty care for beneficiaries in remote areas. This proactive approach will ensure that telehealth remains a dynamic and responsive component of the MA program, adapting to new health care challenges and technological advancements.
Moreover, the NHC recognizes the importance of addressing transportation barriers that prevent beneficiaries from accessing health care services. Acknowledging that transportation-related data is already collected through the Medicare Current Beneficiary Survey (MCBS), the NHC recommends that CMS utilize this existing framework to deepen the understanding of transportation challenges. This could involve refining or adding specific questions within the MCBS to gather more targeted insights into the extent of transportation barriers, their impact on access to health care, and the effectiveness of current solutions.
Furthermore, the NHC recommends that CMS analyze this enhanced data to identify geographic areas and beneficiary groups most affected by transportation challenges. Understanding these dynamics can help CMS and MA plans develop tailored interventions to improve access to health care services. Recommendations could include expanding partnerships with transportation services, community organizations, or exploring innovative solutions like mobile health clinics, which could be more effectively targeted based on the specific needs revealed through the MCBS data. By leveraging the established MCBS, CMS can ensure that interventions to overcome transportation barriers are based on robust, up-to-date data, and that MA plans are equipped to respond with precision to the needs of their beneficiaries.
Conclusion
The NHC appreciates the opportunity to provide comments to CMS in response to its MA data RFI. Please do not hesitate to contact Eric Gascho, Senior Vice President of Policy and Government Affairs, if you or your staff would like to discuss these comments in greater detail. He is reachable via e-mail at egascho@nhcouncil.org.
Sincerely,
Randall L. Rutta
Chief Executive Officer
1 Ochieng, N., Biniek, J., Freed, M., Damico, A., and Neuman, T. (2023). Medicare Advantage in 2023: enrollment update and key trends. Retrieved from https://www.kff.org/medicare/issue-brief/medicare- advantage-in-2023-enrollment-update-and-key-trends/
2 National Health Council. (n.d.). Patient engagement: capturing and including the patient voice. Retrieved from https://nationalhealthcouncil.org/issue/patient-engagement/
3 Revisions to OMB’s statistical policy directive no. 15: standards for maintaining, collecting, and presenting federal data on race and ethnicity, 89 Fed. Reg. 22182 (March 28, 2024).
4 National Health Council. (2022). NHC comments on provider directory RFI. Retrieved from https://nationalhealthcouncil.org/letters-comments/nhc-comments-on-provider-directory-rfi/
5 Request for information; national directory of healthcare providers & services, 87 Fed. Reg. 61018 (October 7, 2022).
8 Kyle, M. and Keating, N. (2023). Prior authorization and association with delayed or discontinued prescription fills. Journal of Clinical Oncology, 42(8). https://doi.org/10.1200/JCO.23.01693
9 Chino, F., Baez, A., Elkins, I., Aviki, E., Ghazal, L., and Thom, B. (2023). The patient experience of prior authorization for cancer care. JAMA Network Open, 6(10). doi: 10.1001/jamanetworkopen.2023.38182
10 Jew, O., Okawa, J., Barbieri, J., McCaffrey, J., Hayward, E., and Werth, V. (2021). Evaluating the impact of prior authorizations with complex dermatological conditions. Journal of the American Academy of Dermatology, 83(6), 1674-1680. doi: 10.1016/j.jaad.2020.06.998
11 American College of Cardiology. (2017). Barriers to new medications for cardiovascular disease: insights from CardioSurve. Retrieved from https://www.acc.org/latest-in- cardiology/articles/2017/02/21/12/42/barriers-to-new-medications-for-cardiovascular-disease-insights- from-cardiosurve?hstc=117268889.c6acac5669d4f1e6063a774e6d96c6b5.1716560813145.1716560813145.1716560813145.1&hssc=117268889.1.1716560813145&hsfp=3523199817
12 Medicare and Medicaid programs; Patient Protection and Affordable Care Act; advancing interoperability and improving prior authorization processes for Medicare Advantage organizations, Medicaid managed care plans, state Medicaid agencies, Children’s Health Insurance Program (CHIP) agencies and CHIP managed care entities, issuers of qualified health plans on the federally-facilitated exchanges, merit-based incentive payment system (MIPS) eligible clinicians, and eligible hospitals and critical access hospitals in the Medicare promoting interoperability program, 89 Fed. Reg. 8758 (February 8, 2024) (to be codified at specified parts of 42 and 45 C.F.R.).
13 National Health Council. (2024). NHC comments on Medicare Prescription Payment Plan. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2024/03/NHC-Comments-RE-MPPP-Part-2- Guidance.pdf
14 National Health Council. (2024). NHC comments on draft CY 2025 Part D redesign program instructions. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2024/03/NHC- Comments-RE-Draft-CY-2025-Part-D-Redesign-Program-Instructions.pdf
15 National Health Council. (2024). NHC comments on advance notice of methodological changes for calendar year (CY) 2025 for Medicare Advantage (MA) capitation rates and Part C and Part D payment policies. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2024/03/NHC-Comments- RE-CY-2025-Advance-Notice.pdf
16 National Health Council. (2022). Access, affordability, and quality: a patient-focused blueprint for real health equity. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2022/01/Access- Affordability-and-Quality-A-Patient-Focused-Blueprint-for-Real-Health-Equity.pdf
17 National Health Council. (2023). NHC comments on Medicare Advantage RFI. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2022/08/Medicare-Advantage-RFI-Letter-Final.pdf
18 Christ, A. (2023). Medicare Advantage plans and supplemental benefits: bridging the data gap for equitable access. Retrieved from https://healthlaw.org/medicare-advantage-plans-and-supplemental- benefits-bridging-the-data-gap-for-equitable-access/
19 National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Committee on Community-Based Solutions to Promote Health Equity in the United States, Baciu, A., Negussie, Y., Geller, A., et al. (Eds.). (2017). Communities in action: pathways to health equity (Chapter 3, The root causes of health inequity). National Academies Press.
20 National Health Council. (n.d.). Patient reported outcomes and patient centered outcomes. Retrieved from https://nationalhealthcouncil.org/webinars/clinical-outcome-assessment-webinar-series-patient- reported-outcomes-and-patient-centered-outcomes/
21 National Health Council. (2023). Patient-focused drug development (PFDD): incorporating clinical outcome assessments into endpoints for regulatory decision-making; draft guidance for industry, Food and Drug Administration staff, and other stakeholders; availability. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2023/07/PFDD-Guidance-4- Comments.pdf#:~:text=The%20National%20Health%20Council%20(NHC)%20thanks%20the,to%20provi de%20input%20to%20the%20proposed%20fourth
22 Health Care Payment Learning & Action Network. (2023). Measuring progress: adoption of alternative payment models in commercial, Medicaid, Medicare Advantage, and traditional Medicare programs. Retrieved from http://hcp-lan.org/workproducts/apm-methodology-2023.pdf
23 AHIP. (2024, April 10). AHIP, the American Medical Association, and the National Association of ACOs release playbook with recommendations toward a sustainable future for value-based care payment [Press release]. https://www.ahip.org/news/press-releases/ahip-the-american-medical-association-and-the- national-association-of-acos-release-playbook-with-recommendations-toward-a-sustainable-future-for- value-based-care-payment
NHC Comments on Response to the Medicare Program; Request for Information on Medicare Advantage Data
05/29/2024
NHC Comments on Response to the Medicare Program; Request for Information on Medicare Advantage Data (PDF)
May 29, 2024
Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244
RE: Medicare Program; Request for Information on Medicare Advantage Data
Dear Administrator Brooks-LaSure:
The National Health Council (NHC) appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) in response to the Medicare Program; Request for Information on Medicare Advantage Data (MA data RFI).
Created by and for patient organizations over 100 years ago, the NHC brings diverse organizations together to forge consensus and drive patient-centered health policy. We promote increased access to affordable, high-value, equitable, and sustainable health care. Made up of more than 170 national health-related organizations and businesses, the NHC’s core membership includes the nation’s leading patient organizations. Other members include health-related associations and nonprofit organizations including the provider, research, and family caregiver communities; and businesses and organizations representing biopharmaceuticals, devices, diagnostics, generics, and payers.
Overarching Comments
The significant growth of Medicare Advantage (MA) in recent years highlights the timeliness of this RFI. As of 2023, 30.8 million individuals, representing 51 percent of Medicare beneficiaries, are enrolled in MA plans, a substantial increase from 31 percent less than a decade ago.1
This trend underscores the importance of informed decision-making for those with chronic diseases and disabilities, who face crucial choices regarding their health care coverage – whether selecting between traditional Medicare and MA, choosing among MA plans, or navigating their selected plan to access necessary care. For people with chronic diseases and disabilities, the stakes for these decisions can be extremely high, and it is critical they have access to the information they need to make informed decisions. The NHC has consistently advocated for the active involvement of patients and their families in decisions that affect their health care. We believe in the power of high-quality patient engagement that is characterized by sustained, reciprocal communication between patients and decision- makers.
We also believe that transparency is paramount to assuring patients are able to make informed decisions. This requires consistency and accuracy of data, which makes this RFI important. As part of CMS’ process, we recommend establishment of an engagement framework that transcends traditional consultation, facilitating a continuous exchange of information. This approach should address queries such as those posed in this RFI, among others, providing CMS with timely insights directly from those most impacted by its policies. Moreover, we urge CMS to collaborate with patient advocates and health care plans to create guidelines for integrating patient perspectives into plan design and operational decisions. For instance, CMS could guide plans on setting up consumer advisory groups that include individuals with chronic conditions and disabilities. These groups would serve as a platform for ongoing input on various aspects of plan operation, from design to quality assessment. The NHC is ready to support CMS in shaping these engagement strategies, drawing upon our extensive experience and toolkit developed over the years for effective patient involvement.2 Patient organizations, often the first point of contact for individuals seeking guidance on navigating the Medicare system, possess invaluable insights into the program’s strengths and shortcomings from the patient’s viewpoint. Leveraging these organizations as partners in establishing a robust patient engagement feedback loop is essential. Through such collaborative efforts, we can ensure that the Medicare system, particularly the MA program, is responsive to the needs and experiences of all beneficiaries, particularly those with chronic illnesses and disabilities.
Health Equity
Health equity is foundational to ensuring high-quality care in the MA program. While existing tools like the Health Equity Index serve to measure disparities, the NHC believes that a more nuanced and comprehensive approach is necessary to capture the full spectrum of factors influencing health equity. To this end, the NHC urges CMS to adopt measures that go beyond current practices by integrating a broader array of social determinants of health (SDOH) data into MA plan assessments. This would include variables such as socioeconomic status, geography, language, and disability status, which are pivotal in understanding and addressing the barriers to equitable care.
Furthermore, we recommend that CMS leverages the newly released Statistical Policy Directive No. 15 to enhance the granularity of race and ethnicity data collection as quickly as possible.3 By doing so, CMS can identify and address health disparities in more specific and effective ways. Moreover, incorporating these detailed health equity metrics into the overall quality measurement and improvement frameworks used to evaluate MA plans will ensure a holistic view of plan performance, not limited to clinical outcomes but extending to equitable care delivery. Such metrics could include patient satisfaction scores disaggregated by detailed demographic categories, alongside analyses of treatment outcomes by population group.
By enriching the data framework and embedding comprehensive health equity measures into the evaluation process, CMS can ensure that all beneficiaries receive care that is not only clinically effective but also equitable and respectful of their diverse needs. This enhanced approach will not only improve individual health outcomes but also strengthen the systemic health of the entire MA program, fostering a more inclusive health care environment.
Beneficiary Engagement
The NHC emphasizes the crucial role of beneficiary engagement in enhancing the effectiveness and responsiveness of MA plans. CMS should require plans to establish a comprehensive engagement framework that mandates ongoing interaction between MA plans and beneficiaries. CMS should require MA plans to implement and maintain platforms for continuous feedback, using the insights gathered to assess the effectiveness of engagement strategies and improve communication.
To this end, the NHC recommends that CMS collaborate with MA plans to:
Addressing the Needs of Special Populations within the MA Program
The NHC recognizes that ensuring equitable access to health care services and improving health outcomes for all beneficiaries within the MA program requires addressing the diverse needs of special populations. Special populations include, but are not limited to, individuals dually eligible for Medicare and Medicaid, individuals who qualify for Medicare not through age but due to a disability, such as those with end-stage renal disease (ESRD) or diagnosed with amyotrophic lateral sclerosis (ALS), and beneficiaries with complex health conditions. These groups face unique challenges that necessitate tailored care approaches and enhanced support mechanisms. The Medicare population is heterogenous, and a one- size-fits-all solution does not adequately address the varied needs of these groups. For instance, individuals dually eligible for Medicare and Medicaid may navigate complex health and social service systems, while people with ALS require the coordination of multidisciplinary services and complex medical equipment and those with ESRD require specialized renal care services that integrate multiple aspects of treatment and support. To ensure that interventions and care models are effectively meeting the needs of these diverse groups, the NHC calls for comprehensive and ongoing research and data collection efforts. This includes studying the effectiveness of various interventions and care models tailored to the specific challenges faced by these populations. CMS should facilitate and fund research initiatives aimed at identifying best practices for serving special populations, with the goal of scaling successful approaches across the MA program. Through targeted research, continuous data collection, and the adaptation of care models to meet specific needs, CMS can ensure that all beneficiaries receive high-quality, equitable care tailored to their individual circumstances.
Building on these overarching considerations, the NHC provides the following responses to the specific areas of interest identified by CMS in this RFI to inform CMS’ efforts in enhancing data collection and release for MA organizations.
Specific Data-Related Recommendations
Beneficiary Access to Care
The NHC underscores the critical need for comprehensive and up-to-date provider directories to guarantee beneficiary access to care within MA plans. NHC members have expressed significant concerns regarding network adequacy, which can significantly impact patient choices and access to needed specialists. To increase patient choice the NHC recognizes the importance of ensuring the accuracy of provider availability by maintaining up-to-date provider directories. Providers are responsible for promptly updating any changes in their service details and responding to health plan inquiries. Equally, MA plans and CMS must create conditions that simplify these updates for providers, ensuring that the process is as straightforward as possible to encourage timely reporting. This includes regular updates to provider directories and enforcing accuracy through mechanisms such as secret shopper surveys.
To support these efforts, the NHC recommends that CMS implement regulations that not only mandate these updates but also streamline the processes involved, making it easier for plans and providers to comply. This could be further enhanced by the development of a National Directory of Healthcare Providers and Services, a centralized resource that could significantly enhance the reliability of provider information. The NHC previously contributed ideas to this initiative, providing recommendations in our response to CMS’ request for information on this subject.4,5 NHC seeks updates on CMS’ progress in developing this directory, which would be a critical step towards ensuring beneficiaries receive accurate and reliable information crucial for making informed health care decisions.
Additionally, the NHC recommends that CMS establish and enforce clear, standardized requirements for MA plans regarding prior authorization and utilization management (UM) practices. Such practices, as currently implemented, can act as barriers to care, delaying or denying necessary treatments for beneficiaries.6,7,8,9,10,11 While we support CMS’ proposal to require payers to report certain prior authorization metrics, such as the list of all items and services that need prior authorization, the percentage of standard and expedited requests that were approved, denied, or approved after appeal, the average and median time between request submission and a decision, we also recognize the importance of evaluating the effectiveness of existing data collection efforts. Given the data collection and reporting requirements already in place or planned, the NHC urges CMS to conduct a thorough evaluation of current transparency efforts related to prior authorization data to assess their impact and effectiveness. This evaluation should inform what additional data collection and reporting requirements are needed. We agree with CMS that increasing transparency in these processes will aid beneficiaries in comparing different health plans and ensure that plans are adhering to CMS’s nondiscrimination policies, including those aimed at aligning benefits between MA and traditional Medicare. Based on the findings of this evaluation, CMS should consider implementing new data collection and reporting requirements to address identified gaps. This approach will ensure that enhancements to data collection and reporting are both justified and targeted, addressing specific needs that are not currently met by existing practices. Such measures will help identify plans that excessively use these practices in a manner that restricts access to care, thereby triggering targeted oversight or corrective actions.
To further understand the full impact of these practices, the NHC suggests that CMS conduct or contract for a comprehensive study to assess the costs and benefits associated with UM, including non-quantifiable effects such as beneficiary anxiety and suffering due to delayed or forgone care. This study would provide critical insights into how UM practices affect patient health outcomes and overall well-being, enabling more informed policy decisions.
Moreover, CMS should enhance transparency by requiring MA plans to make their criteria for prior authorization and UM publicly available, allowing patients and providers to better understand and navigate these processes. The NHC applauds the advancements made in the recent interoperability final rule, which aims to streamline prior authorization processes and improve data exchange across health care systems.12 However, we note that while the rule enhances data sharing capabilities, it does not apply directly to prescription drugs, a significant component of health care for many beneficiaries. The NHC urges CMS to extend the benefits of interoperability to include comprehensive medication information, thereby reducing delays and improving transparency in medication management. This expansion is crucial for ensuring that MA beneficiaries have complete access to the care they need, including timely and appropriate medication therapies.
In light of the Inflation Reduction Act (IRA) of 2022 and the subsequent changes to the Medicare Part D benefit structure, the NHC has expressed concerns regarding potential unintended consequences that may arise, particularly as they pertain to formulary decisions affecting patient access to essential medications.13,14,15 With plans taking on increased financial liability, there is a risk that changing incentives could lead plans to impose narrower formulary access, impacting the most vulnerable patient populations. To mitigate these concerns, the NHC proposes intensified collection and transparency of data on formulary inclusiveness to ensure that necessary medications remain accessible without imposing undue restrictions or high out-of-pocket (OOP) costs on patients.
Supplemental Benefits
The NHC supports the incorporation and targeted expansion of supplemental benefits within MA plans, understanding their pivotal role in holistically addressing the health needs of beneficiaries, particularly through mitigating SDOH.16 Recognizing the profound impact of non-medical factors such as housing stability, nutritional access, and transportation on health outcomes, the NHC emphasizes the need to broaden the scope of these benefits without compromising the core benefits provided under Medicare.17,18 These non-medical factors often serve as the root causes of health disparities, affecting individual’s’ ability to manage chronic conditions, access essential medical care, and maintain overall wellness.19 Furthermore, the NHC encourages CMS to ensure that supplemental benefits are effectively supporting all MA participants, particularly those with chronic diseases and disabilities. It is essential to engage patients in discussions about the design and implementation of these benefits to ensure they meet the real-world needs of those most affected. With the recent implementation of CMS’ expanded reporting framework, new data on the utilization of supplemental benefits is now available. This development provides an invaluable resource for evaluating how these benefits are deployed across different demographic groups. The NHC recommends that CMS thoroughly evaluate this newly available data to understand the usage and impact of supplemental benefits. This evaluation should focus on identifying disparities in access and utilization across various demographic groups, including race, ethnicity, income level, disability status, and ZIP code. Such analysis is crucial for determining whether the current offerings meet the diverse needs of all beneficiaries and for guiding any necessary adjustments to ensure equitable access to these important benefits. As this new data becomes available, it will be instrumental in shaping strategies that not only enhance the scope of these benefits but also ensure they do not compromise the core benefits provided under Medicare.
MA Marketing Activities
The NHC acknowledges the crucial role of marketing in informing MA beneficiaries about their health care options. We recognize that effective marketing strategies are essential for ensuring that beneficiaries are well-informed about the range of available MA plans and can make decisions that best suit their health care needs. Given the importance of clear communication, it is vital that marketing materials are accessible and easily understood, particularly for beneficiaries with cognitive challenges and/or limited health literacy, who may find navigating the complex information presented during the open enrollment period overwhelming. The NHC urges CMS to engage collaboratively with MA plans to track the clarity, accuracy, and transparency of marketing materials and communications. This may include the need for CMS to monitor what information is being provided, how messages were developed with patient engagement, where it is being seen, and what impact it has on plan choice. These are all data sets that CMS can and should track and make transparent.
To support this collaborative approach, the NHC suggests several key strategies. Firstly, we recommend the establishment of comprehensive guidelines by CMS, developed in partnership with MA plans and informed by beneficiary engagement, to ensure marketing materials are easily understandable and accurately represent plan offerings. This includes the use of plain language, alternative languages, and clear explanations that can be easily navigated by all beneficiaries. Secondly, the NHC sees value in ongoing dialogue and cooperation between CMS and MA plans to continuously monitor and review marketing practices. This cooperative approach should aim to promptly identify and address any areas for improvement, ensuring marketing practices align with the goal of informed beneficiary decision-making. Thirdly, the NHC supports the development of educational resources that empower beneficiaries to navigate MA plan options effectively. These resources could include guidelines on what questions to ask and key factors to consider, helping beneficiaries to evaluate how different plans meet their health care needs.
Additionally, the NHC suggests that CMS ensure that MA plans provide CMS and beneficiaries with information to effectively compare plan features directly against other available options, including Original Medicare. Comparison tools, whether created by MA plans or CMS, should be designed to help beneficiaries assess plans based on their individual health care requirements and financial considerations, with MA plans required to supply accurate and comprehensive information to support these tools. To further enhance understanding and informed decision-making, the NHC recommends that CMS make these comparison tools readily accessible to patient organizations, enabling them to better educate their communities about the options and intricacies of MA plans.
Care Quality and Outcomes
The NHC is deeply committed to enhancing care quality and health outcomes within the MA program. Recognizing the significance of these factors in the overall well-being of beneficiaries, the NHC supports a multifaceted approach to improve and measure care quality, emphasizing the incorporation of value-based care models, patient-reported outcomes (PROs), and health equity measures.
PROs are critical in assessing the effectiveness of health care from the patient’s perspective.20 While PROs capture the patient’s voice regarding their symptoms, quality of life, and treatment satisfaction, it is essential to recognize that not all PROs are automatically patient-informed or patient-centered.21 To ensure that PROs truly reflect the patient’s experience and perspective, the NHC recommends that CMS develop guidelines to ensure that PRO measures are both relevant and meaningful to patients. This involves engaging with patients in the development of PRO measures and continually validating these measures to confirm they accurately capture meaningful aspects of patient experience. The NHC suggests that CMS consider including these validated, patient- centered PRO measures in MA plan performance evaluations. This integration would ensure that these important indicators of care quality are consistently captured and used to inform care improvement efforts.
Building on the foundation of patient-centered feedback, the development of regulatory frameworks that promote value-based care models that reward health care providers based on patient outcomes – rather than the volume of services provided – is crucial. These models should be backed by incentives aligned with data that demonstrate their effectiveness in improving health outcomes and reducing costs, incorporating metrics like patient satisfaction and health improvements. Regular reviews of such data are essential, as they allow CMS to adjust incentives to meet the evolving needs of beneficiaries, fostering ongoing innovation and improvements across the MA market.
To underscore the importance of these efforts, it is noteworthy that in 2022, over half (57%) of health care payments from MA plans were tied to value-based care models through alternative payment models (APMs), compared to 41% in traditional fee-for-service Medicare.22 This demonstrates significant progress in the shift towards value-based care within MA and highlights the potential for further advancements through comprehensive support and strategic guidance from CMS.
To effectively support this transformation towards high-quality health care, the NHC recommends that CMS guide MA plans in developing and implementing robust value-based care models that prioritize patient outcomes and cost efficiency, aligning closely with the principles of patient-centered care. Ensuring that health care delivery not only meets clinical standards but also enhances patient satisfaction and manages costs effectively is essential. A platform for the exchange of successful strategies and best practices 23 among plans can accelerate the adoption of proven practices that enhance patient care and promote cost efficiency.
Finally, the NHC emphasizes the importance of transparency in care quality and outcomes reporting. We urge CMS to require MA plans to publicly report detailed quality metrics, including outcomes data, value-based care model performance, and health equity indicators. Making this information publicly available will empower beneficiaries to make informed health care choices and stimulate competition among plans to improve care quality.
Market Competition
Healthy competition with the MA program is widely recognized as beneficial for enhancing the quality and affordability of health care services for beneficiaries. It encourages MA plans to innovate and strive for excellence, ensuring that beneficiaries have access to a range of high-quality options. The NHC acknowledges the importance of fostering an environment where competitive dynamics lead to better service delivery, improved health care outcomes, and more efficient use of resources. CMS’ role in regulating and facilitating market conditions that support fair and beneficial competition is vital for the well-being of all beneficiaries. Robust data collection and analysis are crucial in helping CMS gain valuable insights into the dynamics of competition, identify potential areas for regulatory improvement, and implement policies that foster a healthy competitive environment.
Providing clear, accessible information on plan performance, pricing, and beneficiary satisfaction is crucial for helping beneficiaries make informed decisions. Ensuring that this information is readily available and understandable empowers beneficiaries to make choices based on quality and value, rather than cost alone, fostering a competitive landscape that prioritizes beneficiary satisfaction and health outcomes.
This type of transparency also supports the integrity of the MA market by promoting an environment where all plans have the opportunity to demonstrate their value based on transparent and consistent criteria, encouraging them to continuously enhance their offerings.
Medicare Advantage Prescription Drug Plans (MAPDs)
Medicare Advantage Prescription Drug Plans (MAPDs) integrate prescription drug coverage, presenting unique challenges and opportunities for improving health care delivery. The NHC emphasizes the critical need for seamless coordination between pharmacy benefits and medical coverage to optimize treatment outcomes and enhance patient care. To achieve this, we recommend that CMS mandate clear, accessible information on formulary changes, coverage criteria, and out-of-pocket costs to ensure beneficiaries are well-informed and can manage their health effectively.
Further, strong data collection on formulary review processes is crucial to ensure that MAPDs offer a comprehensive range of essential medications, including access to the latest therapies as they become available. These processes should align with the latest clinical guidelines and be transparent to both providers and beneficiaries, enabling better decision- making and adherence to prescribed therapies. Given the significant impact of pharmaceuticals on patient health, particularly for those managing chronic conditions, CMS should also promote best practices among MAPDs that facilitate enhanced communication and data sharing between health care providers and pharmacists. This integration is vital for preventing adverse drug interactions and ensuring that medication management strategies are as effective as possible.
Moreover, the NHC reiterates concerns regarding the growth of UM practices within MAPDs, particularly for drugs, which have historically received less oversight compared to UM for other services and items. These practices, often serving as barriers to timely access to necessary treatments, should be rigorously evaluated and regulated by CMS to prevent undue delays or denials of care. We urge CMS to require MAPDs to report detailed data on prior authorization and UM practices specifically for medicines, including approval and denial rates and timeliness of decision making. This transparency will allow for targeted oversight and necessary corrective actions, ensuring that UM practices are clinically based as well as fair, efficient, and patient-centered.
Lastly, we recognize the potential for MAPDs to contribute significantly to the advancement of value-based care within the MA program. By incentivizing medication use that is aligned with improved health outcomes, CMS can foster an environment that rewards quality and efficiency in pharmaceutical care. Regular reviews and updates to the incentives for MAPDs that successfully implement these models will be crucial for encouraging ongoing innovation and quality improvements.
Geographic Impacts
The NHC emphasizes the importance of data collection and research to better understand and address the geographic disparities in health care access and outcomes within the MA program. CMS should invest in research initiatives and data analytics to identify gaps in service delivery, monitor the effectiveness of interventions aimed at reducing geographic disparities, and adapt strategies based on evidence-based findings.
Addressing geographic impacts within the MA program is critical to ensuring equitable access to health care services for beneficiaries across diverse regions. The NHC recognizes that beneficiaries in rural and underserved urban areas face unique challenges, including limited health care provider networks, scarcity of specialty care, logistical barriers to accessing health care services, and environmental and social factors negatively impacting their health. To mitigate these challenges and promote health equity, the NHC advocates for several strategic initiatives aimed at enhancing health care delivery and access in geographically diverse settings.
Firstly, the NHC recognizes that CMS already collects extensive data on provider networks within MA plans, particularly in rural and underserved urban areas. To make effective use of this data, the NHC recommends that CMS initiate a detailed analysis to evaluate the current state of these networks. This analysis should focus on examining changes in beneficiary access metrics, patient satisfaction, and health outcomes to thoroughly assess the existing needs and identify gaps in service provisions. With insights derived from this analysis, the NHC then urges CMS to develop targeted incentives to encourage health care providers to join MA networks in these regions and to develop innovative partnerships with community health centers, rural health clinics, and telehealth providers. By basing the expansion and enhancement of provider networks on a comprehensive analysis of existing data, CMS can ensure that interventions are precisely tailored to improve timely access to primary care and specialty services for all beneficiaries, enhancing equity and efficiency across diverse geographic areas.
Secondly, telehealth has emerged as a critical tool for overcoming geographic barriers to health care access. The NHC recommends that CMS continue to support and expand telehealth services within the MA program, including covering a broader range of telehealth- delivered services and removing any remaining regulatory barriers that limit the use of telehealth. Recognizing that the Medicare Payment Advisory Commission (MedPAC) has conducted analyses on telehealth’s impact on health service utilization and outcomes, the NHC suggests that CMS should build on this existing data to continuously monitor and evaluate the effectiveness of telehealth services.24 Ongoing analysis is essential to understand the evolving impact of telehealth, particularly in how it can be further optimized to improve access to preventive services, chronic disease management, and specialty care for beneficiaries in remote areas. This proactive approach will ensure that telehealth remains a dynamic and responsive component of the MA program, adapting to new health care challenges and technological advancements.
Moreover, the NHC recognizes the importance of addressing transportation barriers that prevent beneficiaries from accessing health care services. Acknowledging that transportation-related data is already collected through the Medicare Current Beneficiary Survey (MCBS), the NHC recommends that CMS utilize this existing framework to deepen the understanding of transportation challenges. This could involve refining or adding specific questions within the MCBS to gather more targeted insights into the extent of transportation barriers, their impact on access to health care, and the effectiveness of current solutions.
Furthermore, the NHC recommends that CMS analyze this enhanced data to identify geographic areas and beneficiary groups most affected by transportation challenges. Understanding these dynamics can help CMS and MA plans develop tailored interventions to improve access to health care services. Recommendations could include expanding partnerships with transportation services, community organizations, or exploring innovative solutions like mobile health clinics, which could be more effectively targeted based on the specific needs revealed through the MCBS data. By leveraging the established MCBS, CMS can ensure that interventions to overcome transportation barriers are based on robust, up-to-date data, and that MA plans are equipped to respond with precision to the needs of their beneficiaries.
Conclusion
The NHC appreciates the opportunity to provide comments to CMS in response to its MA data RFI. Please do not hesitate to contact Eric Gascho, Senior Vice President of Policy and Government Affairs, if you or your staff would like to discuss these comments in greater detail. He is reachable via e-mail at egascho@nhcouncil.org.
Sincerely,
Randall L. Rutta
Chief Executive Officer
1 Ochieng, N., Biniek, J., Freed, M., Damico, A., and Neuman, T. (2023). Medicare Advantage in 2023: enrollment update and key trends. Retrieved from https://www.kff.org/medicare/issue-brief/medicare- advantage-in-2023-enrollment-update-and-key-trends/
2 National Health Council. (n.d.). Patient engagement: capturing and including the patient voice. Retrieved from https://nationalhealthcouncil.org/issue/patient-engagement/
3 Revisions to OMB’s statistical policy directive no. 15: standards for maintaining, collecting, and presenting federal data on race and ethnicity, 89 Fed. Reg. 22182 (March 28, 2024).
4 National Health Council. (2022). NHC comments on provider directory RFI. Retrieved from https://nationalhealthcouncil.org/letters-comments/nhc-comments-on-provider-directory-rfi/
5 Request for information; national directory of healthcare providers & services, 87 Fed. Reg. 61018 (October 7, 2022).
6 Jacobsen, G., Leonard, F., Sciupac, E., and Rapoport, R. (2024). What do Medicare beneficiaries value about their coverage? Findings from the Commonwealth Fund 2024 value of Medicare survey. Retrieved from https://www.commonwealthfund.org/publications/surveys/2024/feb/what-do-medicare-beneficiaries- value-about-their-coverage
7 American Medical Association. (2023). 2022 AMA prior authorization (PA) physician survey. Retrieved from https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
8 Kyle, M. and Keating, N. (2023). Prior authorization and association with delayed or discontinued prescription fills. Journal of Clinical Oncology, 42(8). https://doi.org/10.1200/JCO.23.01693
9 Chino, F., Baez, A., Elkins, I., Aviki, E., Ghazal, L., and Thom, B. (2023). The patient experience of prior authorization for cancer care. JAMA Network Open, 6(10). doi: 10.1001/jamanetworkopen.2023.38182
10 Jew, O., Okawa, J., Barbieri, J., McCaffrey, J., Hayward, E., and Werth, V. (2021). Evaluating the impact of prior authorizations with complex dermatological conditions. Journal of the American Academy of Dermatology, 83(6), 1674-1680. doi: 10.1016/j.jaad.2020.06.998
11 American College of Cardiology. (2017). Barriers to new medications for cardiovascular disease: insights from CardioSurve. Retrieved from https://www.acc.org/latest-in- cardiology/articles/2017/02/21/12/42/barriers-to-new-medications-for-cardiovascular-disease-insights- from-cardiosurve? hstc=117268889.c6acac5669d4f1e6063a774e6d96c6b5.1716560813145.1716560813145.1716560813145.1& hssc=117268889.1.1716560813145& hsfp=3523199817
12 Medicare and Medicaid programs; Patient Protection and Affordable Care Act; advancing interoperability and improving prior authorization processes for Medicare Advantage organizations, Medicaid managed care plans, state Medicaid agencies, Children’s Health Insurance Program (CHIP) agencies and CHIP managed care entities, issuers of qualified health plans on the federally-facilitated exchanges, merit-based incentive payment system (MIPS) eligible clinicians, and eligible hospitals and critical access hospitals in the Medicare promoting interoperability program, 89 Fed. Reg. 8758 (February 8, 2024) (to be codified at specified parts of 42 and 45 C.F.R.).
13 National Health Council. (2024). NHC comments on Medicare Prescription Payment Plan. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2024/03/NHC-Comments-RE-MPPP-Part-2- Guidance.pdf
14 National Health Council. (2024). NHC comments on draft CY 2025 Part D redesign program instructions. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2024/03/NHC- Comments-RE-Draft-CY-2025-Part-D-Redesign-Program-Instructions.pdf
15 National Health Council. (2024). NHC comments on advance notice of methodological changes for calendar year (CY) 2025 for Medicare Advantage (MA) capitation rates and Part C and Part D payment policies. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2024/03/NHC-Comments- RE-CY-2025-Advance-Notice.pdf
16 National Health Council. (2022). Access, affordability, and quality: a patient-focused blueprint for real health equity. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2022/01/Access- Affordability-and-Quality-A-Patient-Focused-Blueprint-for-Real-Health-Equity.pdf
17 National Health Council. (2023). NHC comments on Medicare Advantage RFI. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2022/08/Medicare-Advantage-RFI-Letter-Final.pdf
18 Christ, A. (2023). Medicare Advantage plans and supplemental benefits: bridging the data gap for equitable access. Retrieved from https://healthlaw.org/medicare-advantage-plans-and-supplemental- benefits-bridging-the-data-gap-for-equitable-access/
19 National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Committee on Community-Based Solutions to Promote Health Equity in the United States, Baciu, A., Negussie, Y., Geller, A., et al. (Eds.). (2017). Communities in action: pathways to health equity (Chapter 3, The root causes of health inequity). National Academies Press.
20 National Health Council. (n.d.). Patient reported outcomes and patient centered outcomes. Retrieved from https://nationalhealthcouncil.org/webinars/clinical-outcome-assessment-webinar-series-patient- reported-outcomes-and-patient-centered-outcomes/
21 National Health Council. (2023). Patient-focused drug development (PFDD): incorporating clinical outcome assessments into endpoints for regulatory decision-making; draft guidance for industry, Food and Drug Administration staff, and other stakeholders; availability. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2023/07/PFDD-Guidance-4- Comments.pdf#:~:text=The%20National%20Health%20Council%20(NHC)%20thanks%20the,to%20provi de%20input%20to%20the%20proposed%20fourth
22 Health Care Payment Learning & Action Network. (2023). Measuring progress: adoption of alternative payment models in commercial, Medicaid, Medicare Advantage, and traditional Medicare programs. Retrieved from http://hcp-lan.org/workproducts/apm-methodology-2023.pdf
23 AHIP. (2024, April 10). AHIP, the American Medical Association, and the National Association of ACOs release playbook with recommendations toward a sustainable future for value-based care payment [Press release]. https://www.ahip.org/news/press-releases/ahip-the-american-medical-association-and-the- national-association-of-acos-release-playbook-with-recommendations-toward-a-sustainable-future-for- value-based-care-payment