MedPAC Tackles Accuracy of Medicare Advantage Network Directories

Inaccuracies in Medicare Advantage (MA) directories listing in-network providers — often criticized as being too “narrow” — and flaws in rules governing them need to be addressed to prevent situations that are “horrible,” “unfair,” and can harm beneficiaries, some members of the Medicare Payment Advisory Commission (MedPAC) said during its public meeting Friday.

Problems that leave enrollees stranded and confused include:

• MA plans and their providers can terminate their contracts at any point in the year, leaving beneficiaries stranded, but beneficiaries can only change plans during open enrollment for the coming calendar year, leaving them anxious and fearful as they search for other network providers or pay out of pocket
• A doctor who is listed as “in network” may not actually be accepting patients
• MA plans often exclude certain specialty centers, such as National Cancer Institute-designated cancer hospitals, or have restrictions that affect access to allergy and ob/gyn providers

There’s “a truism that you don’t always know what you need ’til you need it,” said MedPAC commissioner Scott Sarran, MD, MBA, founding chief medical officer of Harmonic Health, which is focused on improving dementia care for patients and providers. When “you’re not facing some really critical decisions, you’re not going to think about that when you shop [for a plan], right?” That is one way in which network inadequacy can harm patients, he said.

The commissioners commented at length on a work plan report presented by MedPAC senior analyst Katelyn Smalley, PhD, MSc, who noted that a 2018 evaluation by the Centers for Medicare & Medicaid Services (CMS) found that about half of the MA plan provider directories “had at least one inaccuracy, and inaccurate listings comprised up to 93% of one directory.”

Compounding the problem is that CMS reviews MA plan network adequacy — to assure certain provider types and maximum wait times for appointments meet federal standards — every 3 years, but the review information is provided by the plan “and not independently verified,” Smalley said. CMS can impose sanctions for non-compliance, but “it has never done so,” she noted during a slide presentation about the report. (The report itself has not been made available to the public.)

MA plans have long touted that having a contracted network allows them to weed out lower-value or lower-quality providers. It also enables the potential for greater collaboration among providers in the network who may share the same electronic health systems.

“The fact is, sometimes narrow networks provide quality simply because the relationships exist,” said commissioner Greg Poulsen, MBA, senior vice president at Intermountain Healthcare, an integrated health system based in Salt Lake City. “It’s not necessarily that the provider is a better provider. It’s that they’re more connected with other providers, and they work as a team more effectively.”

But those positive aspects of MA plans start to disappear if patients can’t access their providers when they need them, some commissioners said.

Commissioner Stacie Dusetzina, PhD, a professor of health policy at Vanderbilt University School of Medicine in Nashville, Tennessee, noted what a “horrible” ordeal it is for beneficiaries when plans and providers change networks. “I don’t think it should be allowed, like you should sign up for a contract, and then have a whole year. And if changes are made, it should be in the next year. … I think documenting the churn in these networks is incredibly important.”

Commissioner Amol Navathe, MD, PhD, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, added that “it is seemingly unfair for beneficiaries to be the ones responsible or accountable for network disruptions or for changes to their networks.”

It’s especially unfair, he said, when through underwriting, plans in most states can lock beneficiaries out of purchasing a Medigap or supplemental plan that would pick up co-pays and deductibles if the patients switched to traditional Medicare to stay with their doctors.

Commissioner Gina Upchurch, RPh, MPH, executive director of Senior PharmAssist in Durham, North Carolina, urged MedPAC to look into the idea of imposing financial penalties on plans that inaccurately report their network providers. “Can we have something that says, ‘don’t pay if not reporting correctly?’ It seems insane that we do not have directories that are working well for people.”

As a counselor for the federally funded State Health Insurance Assistance Program, Upchurch related the “inordinate” amount of time she spends trying to verify whether providers are in an MA plan network for beneficiaries looking to enroll. Neither Medicare nor the state insurance agency, nor even the office practice, know whether the doctor is in network the next year, she said.

She described a recent situation when a major health system in her area announced they were canceling its contract with a large MA plan — “the battle of the Titans,” she called it — as of the end of October. After hours spent working the phones, she got the family — all with serious medical conditions requiring specialty care — into a different plan with five stars that allowed movement mid-year. Then “at midnight,” she said, the “Titans” settled. But it was too late to go back.

The family lost their out-of-pocket expenditures and had to start all over with a different plan, and other medical services such as oxygen, had to be re-established.

“The anxiety and the stress that it creates for people is ridiculous,” Upchurch said. “For the health of people, we have to take care of this.”

The MedPAC commissioners’ topic of discussion was the scope of an upcoming staff project that will analyze network requirements and utilization, with the goal of eventually recommending to Congress how changes in network directory requirements would enable MA plans to serve their growing number of beneficiaries far better than they do today.

Some commissioners also pointed out that access to quality post-acute care settings and behavioral health providers within MA plans is challenging in many parts of the country, and facilities and providers that offer better-quality care are much farther away.

“The [federal] network adequacy requirements don’t include quality — that would be hard to do across different sectors,” said commissioner Tamara Konetzka, PhD, a professor of public health sciences at the University of Chicago. “But for the post-acute care sector, it’s really important.”

Brian Miller, MD, MBA, MPH, of Johns Hopkins University School of Medicine in Baltimore, noted that he hears “a lot of anger … in assertions that MA is having lower-quality providers,” which he said is not necessarily true.

“Using this work as a way to be constructive and improve the MA program for beneficiaries is the ethos that we should have instead of just bashing the Medicare Advantage program,” he said.

But Miller also implied that he didn’t understand why the plans can’t be more accurate in their plan directories. For car repairs, he goes to his insurance carrier, types his zip code, and finds all the shops within miles of his house and their prices. “Same for hotels and credit card miles,” he said.

If these industries have solved the problem, MA plans can too, he suggested.