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Medicare Advantage Networks Include Few Black Or Hispanic Physicians, Making Concordant Care Inaccessible For Many.
Health Aff (Millwood)
January 2025
Amal N. Trivedi, Brown University and Providence Veterans Affairs Medical Center, Providence, Rhode Island.
Black and Hispanic patients who receive care from Black and Hispanic physicians have greater use of preventive care. However, receiving care from racially concordant physicians requires that such physicians are included in private insurance plan networks. Using data from 2019, we examined the extent to which racially concordant physicians are available in the Medicare Advantage (MA) program, which disproportionately enrolls Black and Hispanic Medicare beneficiaries, by linking MA physician networks to physician race and ethnicity to measure the diversity of in-network physicians.
View Article and Find Full Text PDFCombining Patient Survey Data With Diagnosis Codes Improved Medicare Advantage Risk-Adjustment Accuracy.
Health Aff (Millwood)
January 2025
David J. Meyers, Brown University.
Under the current Medicare Advantage (MA) risk-adjustment system, plans are incentivized to report diagnosis codes on enrollees' medical claims reflecting additional and more severe health conditions to increase enrollees' risk scores and corresponding plan payments. To improve the integrity of risk adjustment, researchers have proposed four alternative methods to construct risk scores: calculate Hierarchical Condition Categories (HCC) scores excluding diagnosis codes from health risk assessments and chart reviews, calculate HCC scores excluding diagnosis codes most subject to score inflation, use pharmaceutical claims alone, and use self-reported survey responses alone or in combination with diagnosis codes. Using 2016-19 medical and pharmaceutical claims linked to Consumer Assessment of Healthcare Providers and Systems survey responses from 151,432 MA enrollees, we compared the predictive accuracy of each alternative strategy with the standard HCC approach.
View Article and Find Full Text PDFAre Fewer Diagnoses Better? Assessing A Proposal To Improve The Medicare Advantage Payment System.
Health Aff (Millwood)
January 2025
Daniel Waldo, Actuarial Research Corporation.
Medicare Advantage (MA) plans report diagnoses more completely than they are reported in traditional Medicare. As a result, payment to MA plans is greater than it would be if coding patterns were identical in the two sectors. The Medicare Payment Advisory Commission estimates that the overpayment to MA attributable to differential coding was $50 billion in 2024.
View Article and Find Full Text PDFMedicare Risk Adjustment: Goals, Reform Proposals, And New Frontiers.
Health Aff (Millwood)
January 2025
Aaron L. Schwartz University of Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
Risk adjustment modifies payments to health insurers based on enrollee characteristics that are predictive of higher or lower medical spending. Risk-adjustment policy is a key ingredient for the success of regulated individual insurance markets in Medicare and beyond. Researchers have identified shortcomings of Medicare's current risk-adjustment system, illustrated the limits of coarse fixes, and proposed new strategies that improve the data and calculations used to generate beneficiary risk scores.
View Article and Find Full Text PDFThe Burden of Insurance Prior Authorization on Cancer Care: A Review of Evidence From Radiation Oncology.
Adv Radiat Oncol
January 2025
Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee.
Purpose: Despite its high cost-effectiveness, radiation oncology faces the greatest prior authorization (PA) burden of any medical specialty. Insurance denials and resulting treatment delays have been documented across several treatment modalities, including stereotactic body radiation, intensity modulated radiation, and proton therapy. Although insurance companies suggest that PA is intended to control health care spending and ensure the implementation of evidence-based practice, the number of radiation treatment plans reviewed by the PA process that result in changes is quite low.
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