Decoding Medicare Benefit
by Andrew Sprung
Can STAT’s publicity of UHC’s exhortations to goose Medicare Benefit enrollees’ danger scores spur motion to scale back MA overpayment?
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It’s past affordable doubt that the federal authorities’s funds to Medicare Benefit plans are grossly inflated by the plans’ gaming of this system’s danger adjustment system, designed to discourage plans from cherry-picking well being enrollees. The chance adjustment program pays plans extra for enrollees with increased “risk scores,” calculated on the idea of enrollees’ recognized medical circumstances. Plans have varied technique of inflating enrollees’ danger scores — most notoriously, dwelling danger assessments and chart critiques — a retroactive combing of the enrollee’s medical file so as to add new diagnoses.
The upcoding has been so egregious for therefore lengthy that CMS’s is required by statute to chop the plans’ danger scores throughout the board by 5.9%. It’s not sufficient. In its March 2024 report back to Congress, the Medicare Cost Advisory Fee (MedPAC) estimated that in 2022 MA danger scores had been about 18% increased than scores for comparable FFS beneficiaries on account of increased “coding intensity” — the well mannered time period for inflated danger scores. MedPAC forecast that in 2024, the coding depth hole would improve to twenty%. For the 2024 report, MedPAC tailored the methodology (see Ch.13) of former CMS official Richard Kronick, who estimated in 2021 that danger adjustment overpayments would complete $600 billion from 2023 to 2031 if not adjusted.
For a few years, MedPAC has really helpful slicing MA plans’ danger adjustment funds by varied means, essentially the most simple being to extend the 5.9% across-the-board haircut to plans’ danger scores — a minimal imposed years in the past by Congress. However slicing funds to Medicare Benefit plans, which now cowl barely greater than half of Medicare enrollees, is politically tough. This 12 months, CMS in the reduction of for the second 12 months operating on one other supply of overpayment — cost bonuses based mostly on high quality scores, which had been boosted by a pandemic measure — leading to some plans paring additional advantages and others discontinuing service in some areas. Republicans are sure to demagogue these reductions as Medicare Open Enrollment kicks off.
Compelling statistical proof that coding depth is steadily growing MA overpayment has been manifest for years and hasn’t spurred a lot corrective motion. A STAT* exposé this week of stress exerted on physicians to extend diagnoses (“upcode”) by UnitedHealth Group, the biggest MA insurer, might present extra impetus for change than a bevy of high quality statistical research, because it proof of intentional, incentivized upcoding. As UnitedHealth additionally owns doctor practices using 10% of U.S. physicians, it’s in a very robust place to stress docs to upcode — a win-win for the corporate on each the supplier and insurer facet.
STAT obtained emails from UnitedHealth executives to physicians in a single UHC-owned follow exhorting them to diagnose persistent situation.
The “#1 PRIORITY” turned documenting older sufferers’ persistent diseases to generate extra income from the federal authorities, the emails present.
UnitedHealth shared with docs within the follow a dashboard evaluating the share of persistent ailments they discovered amongst their Medicare Benefit sufferers to different practices throughout the firm. Those that accomplished essentially the most appointments with older sufferers obtained a “SHOUT OUT!!” within the messages and had been eligible for as much as $10,000 in bonuses. “We can do this!!” one other e-mail mentioned, encouraging docs who had been falling behind.
One focus of the paperwork obtained by STAT was the Medicare annual wellness go to, a free preventive service that, like home-based well being danger assessments, can be utilized as a possibility to pile on diagnoses:
One doc ranked clinicians based mostly on what number of annual wellness visits they’d accomplished with Medicare Benefit sufferers, and cheered these within the lead. “TOP 10 IN AWVs TOTAL!! SHOUT OUT!!,” the e-mail blared, itemizing the docs with essentially the most visits. The message additionally listed bonuses for conducting extra visits and defined the weekend clinics had been a “win” for sufferers and suppliers as a result of they helped improve coding of persistent circumstances comparable to peripheral artery illness, or PAD, a narrowing of the arteries that carry blood to the legs and arms…
The paperwork present that UnitedHealth’s docs recognized PAD in 47% of their Medicare Benefit sufferers — three to 4 occasions the estimated prevalence of the situation in older People. Every prognosis generates about $3,000 a 12 months in additional funds from Medicare [the STAT reporters have a prior article about UnitedHealth goosing PAD screening].
In 2023, CMS proposed after which handed in considerably watered-down type changes to the danger adjustment program designed to curb “coding intensity” by eradicating some 75 prognosis codes “where there is wid[e] variation in diagnosing and coding” — i.e., extra alternative for upcoding. Richard Kronick, maybe essentially the most trenchant critic of the MA danger adjustment program deemed the changes “baby steps,” although he instructed me, ““I am delighted that CMS has its nose in the tent.” My Could 2023 dialog with Kronick delves into the historical past of MA danger adjustment, the results, and varied proposed options, together with adjusting the annual haircut to replicate the total extent of coding depth as calculated by his methodology, which MedPAC subsequently adopted, albeit with changes enabled by their distinctive entry to “complete enrollment, demographic, and risk-score data (beneficiary-level risk-score data are available to the Commission but not generally available to researchers) for MA and FFS beneficiaries with both Part A and Part B.”**
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* The story is by Stat Information reporters Tara Bannow, Bob Herman, Casey Ross, and Lizzy Lawrence. Casey and Herman are latest Loeb Award winners (and Pulitzer finalists) for a previous exposé of UnitedHealth subsidiary NaviHealth’s use of algorithms to disclaim post-acute care to sufferers in MA plans. Enhance diagnoses, scale back costly therapies: that’s MA’s successful method.
** Limiting the danger comparability on the FFS Medicare facet to enrollees who’re enrolled in Medicare Components A and B (omitting these enrolled in solely one of many two) is necessary and reduces the coding depth estimate considerably, as a result of enrollees in Half A alone particularly are usually more healthy than the overwhelming majority who enroll in each components (many Half A-only enrollees are nonetheless employed). See this submit for a take a look at two views of the results of excluding single-part Medicare enrollees from the danger calculation.
