- Medicare Advantage (MA) payments would increase by 0.25% in 2018 if the changes CMS proposed on Wednesday go into effect, though the coding of medical services may cause an additional 2.5% increase.
- The agency also proposed updates to policies in the Overutilization Monitoring System (OMS), which it created to help ensure compliance with overuse guidance due to the country's opioid epidemic.
- Comments on the proposed changes will be accepted until March 3 and the final payment rates will be announced on April 3.
The importance of the role MA plays in providing health benefits to the country's elderly population is expected to increase. An estimated 0.9 million beneficiaries accounted for the 5% increase in MA enrollment from 2015 to 2016, according to the Kaiser Family Foundation.
Despite the fact that the rate of MA enrollment growth was the slowest in terms of percentage since 2006, the growth "reflects both the influence of seniors aging on to Medicare as well as small shifts in the larger pool of beneficiaries in traditional Medicare switching to Medicare Advantage plans," KFF noted. The Congressional Budget Office expects the country's aging population, which is using more Social Security and requiring more Medicare coverage, to continue to drive most of the federal spending increases over the next decade. In addition, the spending growth for healthcare and retirement programs is significantly contributing to an annual budget shortfall.
Meanwhile, at least some insurance companies that offer MA plans seem to be faring well financially. The 4.5% increase in Aetna's Q4 2016 revenue was attributed to participation growth in Medicaid and MA plans. However, Ipsita Smolinski, managing director at Washington-based firm Capitol Street, told Reuters, "The 2018 update is only a smidge better than flat which I suspect may anger some plans." And a recent study in Health Affairs found MA plans pay hospitals 5.6% less on average for services than fee-for-service Medicare.
Opioid-related overdose deaths in the U.S. increased 200% between 2000 and 2014, and these overdoses caused more than 50,000 deaths in the country in 2015. Payers including Aetna and Blue Cross Blue Shield (BCBS) of Massachusetts, and Cigna have been taking different approaches to address the opioid epidemic. CMS wants to improve how the OMS criteria used for identifying patients who are at risk of abusing opioids is aligned with CDC guidelines for prescribing opioids. It also proposes that Part D sponsors "implement hard formulary-level safety edits based on a cumulative morphine equivalent dose (MED) approach to prospectively prevent opioid overuse at point of sale at the pharmacy."