Higher quality coverage for the next generation

Medicare may be in the distant future for you, or you may be helping a loved one navigate this benefit, or you may currently utilize Medicare. Whatever your situation, this is a crucial benefit that is at an inflection point and Priority Health is at the forefront of working to make it better.

An undeniable success story

As widely reported, more people picked Medicare Advantage (MA) over Medicare fee-for-service (30 million out of the 60 million Medicare beneficiaries) for the first time since the program began offering such a choice on how to receive benefits.

With consistently high-quality ratings, expanded benefits and a record of reaching underserved populations, MA is an undeniable success.?Like many successful programs, MA must evolve to keep pace with technological advances and unintended loopholes so that it can drive quality even higher, promote competition and choice, and produce real value for every federal dollar spent.?

But Medicare Advantage is under scrutiny as enrollment numbers continue to grow to as high as 60% of all Medicare beneficiaries by 2030 while projections that the Medicare Trust Fund will be insolvent by 2031.?

Our regulator, the Centers for Medicare and Medicaid Services (CMS), is rightly pushing Medicare Advantage plans to offer high-quality coverage while saving taxpayers money. But the environment to meet these goals is challenging: for example, a February proposed rate note significantly reduces resources for Medicare Advantage plans if adopted. Consequently, we must engage in serious discussions with policymakers, regulators and other stakeholders over what the future of Medicare generally and of Medicare Advantage specifically should be.?

The political landscape for Medicare Advantage?

Medicare Advantage should be seen as a success story, and our accomplishments at Priority Health are a great example of such success. CMS recognized Priority Health’s HMO/POS and PPO plans with 4.5 stars out of 5 for 2024, the highest rating granted to a Michigan-based plan this year. We also are proud to offer Special Needs Plans to better coordinate care for our most vulnerable members, those who are dually eligible for Medicaid as well as Medicare.?

But Medicare Advantage is not without its challenges as plans face scrutiny from regulators, policymakers and other stakeholders. Last year, CMS initiated changes to how plans measure customers’ health risks as some analysts argued that the prior system created improper incentives. Some health systems question utilization management tools such as prior authorization, leading CMS to issue new administrative requirements on insurers participating in federal programs. Congress is also investigating some plans’ marketing practices, again leading to changes initiated by CMS to address consumer education and prevent misleading marketing.?

How Priority Health engages in the policy debate?

With the potential for major changes to Medicare Advantage, we have a commitment to our members, to our provider partners, and to taxpayers to share our experience with our elected officials and regulators and provide feedback on ways that Medicare Advantage is working as well as ways that it could work better. We work closely with members of Michigan’s congressional delegation; for example, U.S. Senator Gary Peters was one of the lead voices on an annual bipartisan letter to CMS in support of Medicare Advantage.??

To amplify our voice even further, Priority Health is an active member of the Alliance of Community Health Plans (ACHP). I am proud to serve as vice-chair on the ACHP board of directors. ACHP represents the nation’s top-performing nonprofit health companies, which serve tens of millions of Americans in nearly 40 states. ACHP member plans collaborate with providers on high-quality coverage and care, leading the industry in practical reforms. In 2023, ACHP Member companies covered more than one-third of all beneficiaries in 5-Star plans even though ACHP members represent approximately 10 percent of total Medicare Advantage enrollees.?

But ACHP does more than provide advocacy in the halls of Congress. Through our leadership role at ACHP, Priority Health has joined with other similarly minded health plans to develop policies on how the next stage of Medicare Advantage should take shape. We can debate highly technical concepts such as risk adjustment and county-level benchmarks in a meaningful way. While these terms may mean little to the average Medicare beneficiary, getting them right in an increasingly changing—and challenging— health care sector will improve the quality and value of coverage every beneficiary receives while ensuring Medicare’s long-term sustainability.?

MA for Tomorrow?

Over the past few years, we have engaged with our fellow nonprofit plans at ACHP to develop a five-part plan called “MA for Tomorrow.” More than a simple set of policy principles, MA for Tomorrow includes actionable items that would refocus Medicare Advantage on its core mission of providing quality, coordinated care in a fiscally sustainable way.??

We have committed to achieving these five pillars:

1. Raising the bar on quality

2. Improving consumer navigation to help customers better understand their choices

3. ?Recalibrating risk adjustment to improve payment accuracy

4. Modernizing network composition

5. Transforming benchmarks

CMS may be able to implement some of our recommendations—for example, the agency is already considering changes to marketing fees that should improve consumer navigation—while others may require congressional action.??

The average consumer may not feel the impact of these recommendations immediately, but if they are adopted, our customers will see a stronger program over time and taxpayers will see a more sustainable benefit. As ACHP President Ceci Connolly has written, “Taken together, the policies foster greater competition, reduce provider burden, push quality standards higher, enhance the shopping experience and curb improper payments.”?

I hope you can join us in achieving this vision for MA. For more information, you can visit the MA for Tomorrow website. We can ensure that MA is on track to provide high quality coverage and deliver coordinated care for millions of Medicare beneficiaries.?

- PT