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Medicare Advantage Evaluation Requires Transparent Claims Data

Transparent Medicare Advantage claims data is necessary in order to evaluate the program and provide insight into the entire Medicare system.

Medicare Advantage requires transparent claims data for analysis

Source: Thinkstock

By Thomas Beaton

- The growth of the Medicare Advantage (MA)  market requires the release of more claims data to evaluate the commercial and government impact of the program, according to a recent JAMA commentary from the Health Care Cost Institute, ProPublica, and the VA.

“Despite the important and increasing role of Medicare Advantage plans, there is fairly little insight into the relative value Medicare Advantage provides to beneficiaries or the funder, the US taxpayer,” the authors said, noting that MA beneficiaries account for a third of the entire Medicare population.

“This is attributable mainly to a lack of access to comprehensive claims or encounter-level data regarding the Medicare Advantage program for researchers, or even more aggregated information that could be made available to the general public.”

Some researchers have used HEDIS measures to attempt to compare Medicare Advantage to traditional Medicare, but many do not have enough data to conduct in-depth research. In 2013, CMS began to collect more detailed data about Medicare Advantage but decided to halt the release of public data in 2017.

The team argues that releasing Medicare Advantage payment rates would allow the government and taxpayers to form a better idea of how much payers charge for their plans.

The average per-enrollee government payment rate to MA plans was 104 percent of per person costs for traditional Medicare spending in 2017, the authors found. Better claims data may be able to help researchers find further overcharging within the MA program.

“Multiple audits have found that Medicare Advantage plans have overcharged the government by overstating the severity of the diagnoses of patients, and the Department of Justice continues to investigate allegations of medical upcoding against Medicare Advantage plans, although a federal judge did recently strike down a specific Department of Justice allegation,” the team said.

“Given the high stakes, the data should be subjected to evaluation by researchers and, to the extent it does not identify beneficiaries, public and media scrutiny.”

Access to MA claims data would also allow stakeholders to have a better idea of MA health plan quality instead of relying solely on HEDIS quality measures.

Medicare Advantage has been found to delivery higher quality preventive care and higher screening rates, but does not provide higher quality healthcare experiences for beneficiaries with severe illnesses, according to studies the team cited. Releasing MA data would allow analysts to gain more visibility into quality comparisons between Medicare and MA.

“The quality of Medicare Advantage relative to traditional Medicare cannot be thoroughly adjudicated with existing Medicare Advantage data because such data are not comprehensive with respect to all the care enrollees receive or as granular as traditional Medicare data,” the team added.

Releasing Medicare Advantage data would also allow stakeholders to understand how providers interact with and bill the MA program.

CMS offers publicly available data sheets containing information about how providers bill under regular Medicare, which helps stakeholders identify questionable billing practices. A similar dataset for Medicare Advantage could identify improper billing in states with extremely large MA populations.

“In Minnesota almost 60 percent of Medicare beneficiaries are enrolled in a MA plan, and in California and Florida more than 40 percent are enrolled in these plans,” the team said.

“The addition of Medicare Advantage data to these releases would provide more complete information about physicians’ interactions with the Medicare program and its beneficiaries and could permit researchers and the media to examine differences between practice patterns for patients in the two programs.

The team believes that the time is right to release more information on Medicare Advantage as the health system comes under increasing scrutiny from the public.

“Researchers, and subsequently, the media have done a notable job identifying the gaps and limitations of the data while underscoring the value of the data and creating important and meaningful research and reporting,” the team concluded.

“There is no compelling reason to think that the same cannot be accomplished for Medicare Advantage, if only the equivalent data were released.”

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