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Hearings & Meeting Analyses

GAO Report on PFFS Plans NEW!

Medicare Advantage: Where Is It Now, And Where Is It Going?

Workgroup Meeting

9/19/08

06/06/08

Medicare as a Building Block for Health Reform: Should Americans Buy In?

05/22/08

Seniors at Risk: Improving Medicare for Our Most Vulnerable

02/07/08

02/07/08

02/05/08

01/30/08

12/06/07

11/08/07

Date: Dec. 16, 2008
Title: Medicare Advantage: Characteristics, Financial Risks, and Disenrollment Rates of Beneficiaries in Private Fee-for-Service Plans, GAO report
Organization: Briefing on GAO report hosted by Committee on Ways and Means, Committee on Energy and Commerce, and Committee on Oversight and Government Reform
Participants: GAO

Summary: GAO staff shared key report findings from their assessment of financial risks and disenrollment rates in PFFS plans, including the significantly higher and unexpected cost-sharing amounts faced by beneficiaries in PFFS plans if they did not contact their plan in advance for specific services.  In addition, the high rate of disenrollment from PFFS plans is not currently available to beneficiaries, which limits their ability to consider this additional “consumer satisfaction” indicator when making informed choices about enrolling in an MA plan.

Outcome: The report makes specific recommendations for executive action by CMS, including investigating the extent to which beneficiaries face unexpected out-of-pocket costs, ensuring that CMS guidance on prior authorization is an accurate reflection of CMS policy, and sharing PFFS plan disenrollment rates with beneficiaries as required by statute.  Attention and action on these issues by CMS will help to ensure that beneficiaries receive appropriate healthcare and do not incur unexpected financial risks.

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Date: November 24, 2008
Title: Medicare Advantage: Where Is It Now, And Where Is It Going?
Organization: Health Affairs Briefing at The Kaiser Family Foundation
Participants:

• Marsha Gold, Mathematica Policy Research, Inc.
• Bryan Dowd, University of Minnesota
• Liz Fowler, Senate Finance Committee
• Kristin Bass, Senate Finance Committee
• Simon Stevens, Ovations, UnitedHealth

Summary:  Brief presentations on two new Health Affairs articles assessing the policy implications of Medicare Advantage were provided—“Medicare’s Private Plans: A Report Card on Medicare Advantage” (Marsha Gold) and “Medicare Advantage Plans at a Crossroads—Yet Again” (Robert Berenson and Bryan Dowd). The presentations were followed by discussions around anticipated Medicare Advantage reform efforts in Congress in the coming year. HAP will continue to monitor these and other privatization issues in Medicare, and will provide updates around upcoming Medicare reform activity in Washington.

Outcome: Changes in the ways in which MA plans operate will likely impact benefits provided to beneficiaries.

Summary:  CMS presented a few notable updates to the Plan Finder, including the option to view the costs of other drugs within the same therapeutic class and the inclusion of the criteria for prior authorization requirements. Consumer advocacy groups raised their fears about fewer LIS qualified plans. They also voiced concerns with the fact that the LIS benchmark is lower than it should be due to the calculation using both PDP and MA-PD premium information.

Outcome: This workgroup has long encouraged CMS to require plans to publish the criteria for prior authorization requirements. In fact, at our last meeting in February, CMS assured the group that these criteria would be available in the upcoming Plan Finder. This workgroup’s advocacy on behalf of consumers, providers, and SHIPs has led to real improvements to the Plan Finder tool.

• Ed Howard, Alliance for Health Reform
• Karen Davis, The Commonwealth Fund
• Cathy Schoen, The Commonwealth Fund
• Hon. Tom Price, Representative (R-GA)
• Steve Lieberman, Lieberman Consulting, LLC
• Cybele Bjorklund, Staff Director, House Ways and Means Health Subcommittee
• Gail Wilensky, Project HOPE

Summary: This briefing addressed the topic of building a national health care system to cover individuals under age 65 through a “national insurance connector.” The “connector” would provide individuals and small firms with a choice between private plans or Medicare-Extra, a new national plan modeled off Medicare. In addition, the new system would require all Americans to be insured with responsibility shared between firms and employees. Employers could provide insurance or pay a seven percent tax on workers’ earnings to finance coverage in the national system. Expanded versions of Medicaid and State Children’s Health Insurance Program (SCHIP) would provide coverage for low-income adults and children below 150 percent of the federal poverty line.

Outcome: Panel proponents support this model because it provides a public-private means of sufficient benefits for children and adults, strong preventive benefits, and Medicare buy-in options for near-elderly adults.

Opponents of the model conveyed that a new health care system should not be based on Medicare due to the program’s low reliability and bottom-line, rather than a patient-centered, approach.

• Senator Herb Kohl (D-WI), Chairman
• Senator Gordon H. Smith (R-OR), Ranking Member
• Lisa Emerson, Program Manager, The Senior Health Insurance Benefits Assistance (SHIBA)/ Director, Oregon State Health Insurance Counseling and Assistance Program, Salem, OR
• Judy Korynasz, Beneficiary witness, caregiver for her mother, Hillsboro, OR
• Barbara Bovbjerg, Director, Education, Workforce and Income Security Issues, US General Accountability Office, Washington, DC
• N. Joyce Payne, Member, AARP Board of Directors, Washington, DC
• Laura Summer, Senior Research Scholar, Georgetown University, Health Policy Institute, Washington, DC

Summary: This hearing addressed the Low Income Subsidy (LIS) program of Medicare Part D. The Government Accountability Office (GAO) presented enrollment data for the LIS program. Other testimony described that increasing or eliminating the asset limits and streamlining the application process would improve enrollment rates by enabling more beneficiaries to qualify for LIS assistance. Discussion also covered the shortage of physicians who currently accept Medicare.

Outcome: The knowledge shared at this hearing will be used to advise the committee when considering Medicare legislation expected to be voted on in June. Although the proposed legislation largely addresses the physician shortage, panelists wanted to assure that improvements are considered for the LIS program.

Date: February 7, 2008
Title: Medicare Advantage Costs, Benefits, & Oversight: The Beneficiary Experience
Organization: U.S. House Committee on Ways and Means; Subcommittee on Health
Participants:

• Kerry Weems, Acting Administrator of CMS
• James Cosgrove, Acting Director, Health Care Issues, U.S. Government Accountability Office (GAO)
• Byron Thames M.D., Board of Directors, AARP
• James Matters, President and CEO, Grande Ronde Hospital, La Grande, Oregon
• David Lipschutz, Interim President and CEO, California Health Advocates
• Daniel Lyons, M.D., Senior Vice President, Government Programs, Independence Blue Cross, Philadelphia, PA

Summary: This hearing was in response to a GAO investigation, which found higher federal spending on Medicare Advantage (MA) did not reduce cost sharing burdens for beneficiaries. Acting Director Weems described concerns that the report did not reflect the benefit of the choices beneficiaries had when choosing Medicare Advantage coverage.

Other testimonies underscored GAO's findings and also requested that the extra money being paid to MA needed to be re-evaluated. One exception was Mr. Lyons' testimony who described the value of MA plans as compared to Original Medicare.

Outcome: Many House members wanted to see more data about how MA plans are spending federal payments and how it is being used to improve services for beneficiaries.

Date: February 7, 2008
Title: Selling to Seniors: The Need for Accountability and Oversight of Marketing by Medicare Private Plans
Organization: Senate Finance Committee
Participants:

• Michael McRaith, Director of Insurance, Division of Insurance, State of Illinois, Springfield, IL
• George Harper, Mayflower, AR
• Peter Hebertson, Director of Outreach for Salt Lake County Aging Services, Salt Lake City, UT
• Patrick O'Toole, Vice President, Humana, Louisville, KY

Summary: Testimony was presented to Senators Baucus (MT), Grassley (IA), Wyden (OR), Lincoln (AR), Stabenow (MI), and Snowe (ME). Three testimonies focused on the same issue – marketing abuses by Medicare Advantage (MA) plans are still rampant and negatively impact Medicare beneficiaries around the country. Commissioner McRaith, Illinois' Insurance Commissioner, who also spoke on behalf of the National Association of Insurance Commissioners (NAIC), and Mr. Hebertson, a SHIP counselor, both supported the idea of states having more oversight over MA plans similar to their oversight of Medigap plans.

Outcome: In 2007, Senator Wyden introduced a bill (S.1883), which would impose more standardization, transparency, and accountability on Medicare Advantage plans, and invest states with greater plan oversight. If passed, SHIPs could see increased state oversight, a reduction in their caseloads, and easier counseling sessions due to the uniformity of plans.

Date: February 5, 2008
Title: Workgroup Meeting
Organization: Centers for Medicare and Medicaid Services/American Medical Association
Participants:

• Centers for Medicare and Medicaid Services (CMS)
• American Medical Association (AMA)
• Center for Medicare Advocacy (CMA)
• National Council on Aging (NCOA)
• Medicare Rights Center (MRC)
• American Bar Association (ABA) Commission on Law and Aging
• Various Provider Groups

Summary: The CMS/AMA Workgroup meets regularly to discuss issues surrounding the implementation of Part D. This meeting primarily focused on the following topics:

• Difficulty obtaining information from Special Needs Plans
• Quality and reporting data about appeals
• The Part D plan rating system
• New requirements in he Draft Call Letter

Outcome: This workgroup has long encouraged CMS to require plans to publish the criteria for prior authorization requirements. The recent draft of the 2009 Call Letter, in fact, requires plans to post this information on their websites. CMS indicates that future improvements to the Plan Finder and the Formulary Finder will have this information as well.

Date: January 30, 2008
Title: Private-Fee-For-Service Plans Medicare Advantage: A Closer Look
Organization: Senate Finance Committee
Participants:

• Mark E. Miller, Ph.D Director, Medicare Payment Advisory Commission, Washington, DC
• Elyse Politi SHIP Coordinator, New River Valley Area Agency on Aging, Pulaski, VA
• Dr. Albert W. Fisk. Medical Director, The Everett Clinic, Everett, WA
• Daryl Weaver, Administrator and CEO, King's Daughters Hospital, Yazoo City, MS
• David Fillman, Executive Director, AFSCME Council 13, Harrisburg, PA

Summary: Senators Baucus (MT), Grassley (IA), Smith (OR), Lincoln (AR), Wyden (OR), and Stabenow (MI) heard testimony on Private-Fee-For-Service (PFFS) plans, a type of Medicare Advantage plan. In opening statements, Senators Baucus and Grassley clearly indicated that the Committee was well aware of PFFS plan financing, enrollee, and provider issues. Witnesses testified about a range of issues including that the plans are not providing enhanced services despite increased federal funding. Providers testified about the lack of timely payments and the refusal by physicians, hospitals and other providers to accept PFFS plan coverage to the detriment of their long-time patients.

Outcome: This hearing was the first in a series on Medicare Advantage plans with a focus on PFFS plans. The senators present seemed poised to address, through legislation, some of the systematic problems experienced by Medicare beneficiaries, their providers and SHIPs. Contemplated legislation includes reducing funding for PFFS plans, standardization of benefits, and increased regulation at the state and federal levels.

Date: December 6, 2007
Title: Increasing Participation in Low-income Programs: Policy Options
Organization: Medicare Payment Advisory Commission (MedPAC)
Participants: MedPAC Commissioners, Presenters: Joan Sokolovsky and Hannah Neprash

Summary: The MedPAC Commissioners re-convene to discuss the policy recommendations presented at the previous month's meeting. The month gave MedPAC staff time to research questions presented by the Commissioners and present findings in time for the Commissioners to vote on the recommendations.

Outcome: All three recommendations, one of which is an increase in SHIP funding, were unanimously accepted.

Date: November 8, 2007
Title: Increasing Participation in the Medicare Savings Programs and Low-Income Drug Subsidy
Organization: Medicare Payment Advisory Commission (MedPAC)
Participants: MedPAC Commissioners, Presenters: Joan Sokolovsky and Hannah Neprash

Summary: MedPAC staffers presented three recommendations intended to increase participation in the Medicare savings programs and low-income drug subsidy.

Outcome: One of the draft recommendations requests that the Secretary "increase SHIP funding and the SHIPs should use the additional money to support work to increase participation in programs targeted to low-income Medicare beneficiaries.