The backlash against Medicare Advantage is here. The best cure for what ails the program is to demand accountability from users and abusers.
As the CEO of a senior health company, I believe Medicare Advantage is the best chance taxpayers and consumers have had in decades to transform medicine from sick care to health care. The idea is to offer incentives for private businesses to improve overall health — and reduce overall costs — by focusing on wellness and prevention over traditional fee-for-service medicine for doctors and heads in beds for hospitals.
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Recently, however, the news has been filled with stories about the downside of Medicare Advantage — deceptive advertising, coverage denials and accounting maneuvers that are making the plans more expensive per person than traditional Medicare. These challenges are getting scrutiny that is unusually bipartisan in the U.S. House and Senate. Meanwhile, the Centers for Medicare and Medicaid Services is trimming Medicare Advantage base rates after insurers deployed extensive coding strategies to maximize revenue.
With more than half of all eligible Americans, or 30.8 million seniors, now enrolled in Medicare Advantage, this program is too important to be sullied by such abuses.
Medicare Advantage was supposed to come with a carrot and a stick. The carrot on the business side was opportunity in a new sector of healthcare. The carrot for consumers was additional benefits, such as vision, dental and hearing coverage, often with no extra premium cost.
What’s been lacking with all the carrots, though, is a stick of accountability. Medicare Advantage funds should come with responsibilities. The four main groups supporting Medicare Advantage — payers, providers, patients and policymakers — are like a table with four legs. We need each one to hold up their end of the deal.
For payers, a successful Medicare Advantage program should promote long-term community health. Guiding customers to stop smoking upfront is cheaper and easier than treating lung cancer at the end. Warding off obesity is healthier and more efficient than treating heart attacks, strokes and diabetes. In-home care and providing modifications like handrails and ramps help seniors live independently instead of moving into expensive long-term care facilities. Payers need to be more proactive and less reactive. If payers don’t work harder to keep customers healthy up front, then they will continue to be hit with the stick of greater costs to treat illness.
There’s been lots of political attention to financial gaming of the healthcare system, such as provider upcoding and overbilling, but payers also need to make accountability a top priority. Payer reimbursement should be driven by value, not volume.
Although some Medicare Advantage investors have decried rising medical expenses, much of the problem comes from a failure by health plans to fully commit to needed reforms. Costs will come down when we focus on providing services that address long-term health and are proactive, predictive, comprehensive, holistic and centered on what customers want, not the fee-for-service churn that too many health systems are programmed to deliver.
Healthcare providers also need more accountability. Is there any profession besides medicine that routinely orders products and services without even knowing the final price for the customer? Cost/benefit can’t be fairly evaluated when medical bills typically are delayed for weeks after a procedure. Will that MRI or blood work advance health, or just extend a medical office routine? Like payers, providers should be evaluated on the quality of their results, not just the volume of services or procedures.
Consumers also need to be part of the accountability equation. Too many seniors reach the end of life with their wishes unclear. Do they want to preserve life by any means possible with a team of surgeons in a hospital, or do they prefer a quieter ending with family and palliative care at home? It’s one of the most personal choices we can make, but thousands of people never make clear to loved ones how they want to go. Without end-of-life directives, seniors risk traumatizing not only themselves, but also their family, friends and medical team. Personal medical accountability means having a plan.
The fourth leg of the accountability table belongs to policymakers. Washington has made it clear that our country spends too much on healthcare — 17% of our gross domestic product, far more per capita than any other advanced country. Accountability from policymakers requires more transparency on what works and what doesn’t. Why has Medicare Advantage become more costly per person than traditional Medicare? Is the program being tainted by a few bad apples, or does the bushel basket itself need strengthening?
I believe the philosophy behind Medicare Advantage is sound. Healthcare will be better and cheaper if it is driven more by results, but we need a clear vision of success. In the same way that quick-buck financial gimmicks need to be called out, regulators need to highlight and reward the innovations that improve these plans.
Medicare Advantage is the program with the best chance to improve health for seniors while trimming bureaucracy and costs for taxpayers. With a push for shared accountability, we can make it work.
Joel Theisen is founder and CEO of home health company Lifespark.
