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Medicare Advantage (MA Part C) is an alternative to traditional Medicare that offers a way to get hospital insurance (Part A) and medical insurance (Part B) benefits and is offered through private health insurance plans.1
In Part One, we explored in more detail what Medicare Advantage entails and potential issues around care coordination, coverage limitations, and transparency challenges. In this continuation, we will delve into the urgent data-centric issues of MA, such as data/payment systems, lack of standardized metrics, data sharing barriers, and solutions and recommendations. These issues require regulatory attention to help improve quality care of the beneficiaries and support providers in times of difficulties. Here at Maxwell TEC, we are committed to helping post-acute care agencies navigate these pressing challenges and provide resources to overcome them.
Data fragmentation is a significant issue in the healthcare world. It causes a distribution of information across multiple platforms, hindering patient care and provider efficiency. According to McKnight's study, approximately one trillion dollars is wasted on healthcare spending, and roughly $500 billion to $750 billion of that could be eliminated by better utilization of data.2 Each MA plan, managed by private insurers, may use different data management systems, which ultimately can create inconsistencies in storage and processing methods. To address some of these issues, the Centers for Medicare and Medicaid Services (CMS) have recently taken actions to increase transparency, specifically requiring Medicare Advantage insurers to post data on timeliness and prior authorization beginning in 2026.3
Another data-centric issue facing MA is the need for standardized metrics consistent in evaluating the performance and quality of healthcare services. As Medicare Advantage lacks consistent metrics, plan evaluations and patient outcomes are negatively affected. Inconsistent metrics hinder the ability to compare plans accurately, leading to variability in care quality and patient satisfaction. This lack of standardized metrics has resulted in inconsistent care for beneficiaries. A recent Hospice News article uncovered staggering statistics regarding MA beneficiaries' end-of-life care. Results indicated that MA beneficiaries were 1.6% less likely than those with traditional Medicare to receive aggressive treatment during the last six months of life and 3.3% less likely to die in a hospital.4 With standardized metrics, it becomes easier to accurately compare the performance of different MA plans, leading to an improvement of patient satisfaction.
The issue of data sharing in healthcare, specifically surrounding Medicare Advantage, set regulatory and technical obstacles that limit seamless exchange of information. Organizations and Associations have requested CMS to increase data transparency. Data sharing is stated to help agencies and research institutions verify whether procedures are positively impacting the overall health of the patent and to better understand their MA beneficiaries needs.5 As previously stated, CMS has taken some steps to help improve the transparency of MA specific data, but there is still a significant of data not reported or published. Some examples of data not reported to CMS are reasons for prior authorization denials and benefits and cost sharing for employer/union plans. Data reported but not published consist of out-of-pocket spending and other payment information for Medicare covered services, and names of employers/unions that sponsor MA retiree plans.3 By improving on this issue, agencies can provide better care for their patients and understand their needs in a clearer way.
Addressing these data-centric issues, healthcare providers can implement integrated data management platforms to ensure consistency and accessibility. Developing these standardized metrics requires collaborative efforts from stakeholders, providers, and regulators to establish concise performance measures. CMS has taken recent actions to address and fix these issues by increasing requirements for private issuers. Technology reforms and regulatory changes play vital roles in driving these changes, offering hope for a more efficient and effective healthcare system. These advancements will help improve quality care, patient outcomes, provider efficiency, and agency outcomes. For Medicare Advantage, addressing these issues is vital for the future success of the program.
This blog was originally published as " Data-Centric Issues Facing Medicare Advantage" by Shea Swenson on 10/1/24, for Maxwell Healthcare Associates. The Maxwell TEC editorial team has since updated this article to ensure accuracy and relevance.