Medicare Advantage Rx Drug

CMS-Sponsored Report Shows Medicare Advantage Members Encounter Significant Racial Disparities

Medicare Advantage members can experience markedly different outcomes in measures related to prescription drugs based on race and/or ethnicity that ultimately impact their overall quality of care, according to the CMS Office of Minority Health’s latest report on health disparities in MA. The report, “Disparities in Health Care in Medicare Advantage by Race, Ethnicity, and Sex,” was funded by CMS and conducted by RAND Health Care’s Quality Measurement and Improvement Program. The report authors studied both the 2021 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the 2021 Healthcare Effectiveness Data and Information Set (HEDIS), highlighting disparities in several clinical areas. In addition to the prescription drug measures illustrated in the graphics below, the report also covered other clinical care measures such as cancer screening rates and patient experience measures including the ease of getting medical appointments and customer service experiences.

As Audit Season Picks Up, CMS Is Scrutinizing Rx Access Issues

As Medicare Advantage plans and their providers operate under a new normal two-and-a-half years into the COVID-19 public health emergency (PHE), CMS is resuming its regular pace of auditing MA organizations as another program audit cycle gets underway, according to compliance experts. During a June 21 session of AHIP 2022, held in Las Vegas, panelists observed that CMS continues to be focused on ensuring seniors’ smooth access to prescription drugs and emphasized the importance of audit readiness.

CMS’s audit activity was limited during the previous cycle, especially in 2020, and its latest audit report reflected that. Released in June, the 2021 Part C and Part D Program Audit and Enforcement Report said CMS imposed 16 civil monetary penalties amounting to roughly $1 million and, between 2019 and 2021, it audited about 20% of currently active sponsors representing approximately 89% of Parts C and D enrollment — which is lower than CMS’s typical goal of 95%.

Plans Build Trust, Mine Data to Dash Medication Adherence Barriers

When it comes to medication adherence rates, disparities among racial and ethnic groups pose a common challenge to health plans. But leaders in the Medicare Advantage space are working to disrupt the status quo with patient-centric, data-driven solutions that are helping to bridge the gap.

A recent initiative at SCAN Health Plan, a not-for-profit insurer serving 270,000 MA members in Arizona, California and Nevada, sought to narrow the gap between member groups by engaging in a top-down endeavor that wrapped in multiple departments, from human resources to pharmacy. “Our goal was to improve adherence,” relays Romilla Batra, M.D., chief medical officer with SCAN, “and to reduce gaps among African American and Latinx [members].”

Plan Finder Update Leaves Out Detail on Supplemental Benefits

As CMS continues to seek ways to improve its consumer-facing tools for comparing Medicare coverage options, the agency last month unveiled a series of tweaks to the website and Medicare Plan Finder (MPF). The MPF in 2019 underwent a major makeover that reportedly cost the Trump administration $11 million but critics say fell short of fixing many of the issues highlighted in a July 2019 report from the Government Accountability Office. CMS has continued to make updates based on consumer feedback, but some industry experts suggest more detail around the supplemental benefits offered by Medicare Advantage plans would be useful.

“CMS is making easier to use and more helpful for people seeking to understand their Medicare coverage, which is an essential part of staying healthy,” said CMS Administrator Chiquita Brooks-LaSure in a May 18 press release. “We are committed to listening to the people we serve as we design and deliver new, personalized online resources and expanded customer support options for people with Medicare coverage and those who support them.”

Enforcement Actions Show Mounting CMPs from Financial Audits (with table: CMP Amounts Imposed on Medicare Advantage Insurers From February to April 2022)

Between February and April of this year, CMS imposed a total of nearly $1 million in civil monetary penalties (CMPs) on Medicare Advantage and Part D organizations for program violations uncovered during routine audits, including so-called “one-third financial audits.” While CMS has yet to release its annual report that provides a fuller picture of plan noncompliance, the latest round of CMP notices offers some important lessons for sponsors and flags a few potential areas of risk that they should be monitoring in their own operations, according to compliance experts.

Of the 15 CMP notices recently posted to the CMS Part C and Part D Enforcements Actions webpage, six resulted from 2021 program audits and eight were related to 2020 financial audits. Additionally, CMS imposed a fine on Anthem, Inc. for a Part D appeals violation stemming from a previously detected system migration issue that occurred in 2020.

Despite Growth, Barriers Remain to Driving Benefit Innovation

Innovative, mostly non-medical supplemental benefits have seen tremendous growth in the few years the Medicare Advantage program has allowed them. But that growth is still from a base of zero, and industry experts suggest that numerous barriers are keeping adoption of these new supplemental benefits at a relatively slow pace.

Starting with plan year 2019, MA organizations began offering a wider range of benefits such as Adult Day Care and In-Home Support Services thanks to CMS’s reinterpretation of the definition of “primarily health-related supplemental benefits.” And with the passage of the CHRONIC Care Act of 2018, MA plans in 2020 began offering Special Supplemental Benefits for the Chronically Ill (SSBCI), a category of “non-primarily health related” items and services that can be made available to certain beneficiaries.

Infographic: Out-of-Pocket Prescription Drug Costs Remain a Burden for Medicare Beneficiaries

Most older adults in the U.S. have been diagnosed with one or more chronic illnesses, and managing these conditions presents a significant cost burden, according to a January study in JAMA Internal Medicine. The authors studied eight of the most common chronic conditions, both as single disease states and in clusters, and determined hypothetical annual out-of-pocket (OOP) costs for individual seniors enrolled in Medicare Advantage-Prescription Drug plans and Standalone Part D plans in 2009 and 2019. While annual costs for many of the conditions dropped, likely due to the availability of new generic drugs, OOP costs for atrial fibrillation, type 2 diabetes and heart failure skyrocketed. This was attributed to the introduction of brand-name therapies without generic alternatives that received clinical guideline recommendations. To remedy this, study authors urged Congress to act on drug pricing reforms, including allowing Medicare to negotiate list prices and cap annual OOP costs for seniors.

In Blow to PBMs, CMS Floats Reform of Part D Price Concessions

As part of a sweeping new Medicare Advantage rule, CMS recently proposed a policy aimed at reforming a reimbursement system that local pharmacies have long claimed is straining them to the breaking point. PBMs, on the other hand, argue that the proposal could hamper value-based contracting in Part D and potentially increase Medicare spending.

At issue are arrangements in which Part D plan sponsors can recoup money from pharmacies for dispensed drugs if the pharmacies do not meet certain metrics. Generally speaking, these payments to plan sponsors are known as price concessions, and when assessed retrospectively — as they currently are — they are counted as direct and indirect renumeration (DIR).