CHICAGO — I was drawn into the provider payment conversation early and often at the LeadingAge conference here this week, but the tone wasn’t quite what I expected.
After years of dark messaging on Medicare Advantage, providers and their advocates suddenly sound, dare I say it, hopeful?
Now don’t get me wrong. No one here thinks MA plans are any less threat to a providers’ bottom line than they’ve been all along. Those concerns are still rampant, especially with some plans’ daily skilled nursing payments trending below state Medicaid reimbursements.
But when it comes to some of the practices that have limited access to care and often cut skilled nursing providers out of the care continuum before patients or their physicians are ready to go home, things are sounding up.
“If you had asked me a year, year and a half ago, ‘Will we see any changes, will they ever listen to us? Will there be better opportunities for providers to make sure beneficiaries actually have access to the care they’re supposed to have access to?’ … I would have said the likelihood of any change is kind of slim,” LeadingAge Vice President of Integrated Services and Managed Care Nicole Fallon told a packed session Tuesday afternoon. “Boy, have things changed.
“There is a cacophony of activity and noise around what’s happening in Medicare Advantage. What that means is, it’s good for us,” added Fallon, who not that long ago used a formal comment letter to warn the Centers for Medicare & Medicaid Services that MA was sending the aging service field into a “death spiral.”
A series of government watchdog reports and intense Congressional scrutiny — including a Homeland Security & Government Affairs Committee investigative hearing into denials and delays — have given providers and patients new platforms to press for change.
And those efforts appear to be working.
While CMS is barreling forward with its stated goal to move all Medicare beneficiaries to some form of accountable care relationship by 2030, recent regulations do at least attempt to rein in some of the most prevalent consumer and provider complaints about MA insurers.
Earlier this week, even as its last MA upgrades sink in, we saw a new, 486-page set of proposed regulations that would remove some financial incentive from marketers pressing patients into MA plans — a major concern among providers who say their patients often don’t know they’re no longer covered by traditional Medicare.
That same rule also offers promising relief to skilled nursing providers, whose patients are often denied post-acute SNF services or have their stays cut short by insurers, even when their healthcare providers think they need more care. A proposed change would make it easier for patients to appeal those kinds of decisions to a third-party reviewer at an early stage.
These kinds of changes are huge news for an insurer subsegment that has largely been allowed to run rampant.
But for skilled nursing and other aging services providers, the concerns stretch far beyond the areas CMS has already tackled.
And it’s critical that Congress and observers within federal health agencies keep the heat on, especially as MA plans become more powerful with every percentage of Medicare patients they pick up now that they’re over the 50% mark.
The LeadingAge Health Care Payment Learning Action Network held a day-long summit on accountable care on Oct. 31, after which Fallon reported that CMS Principal Deputy Administrator & Chief Operating Officer Jon Blum said that “CMS will have less impact overtime” as most care shifts to managed care. That had to be scary to hear for providers who say there is still plenty left to fix about the managed care system.
Fallon said Tuesday that she still wants to see more standardization across plans, particularly on the process side; better interoperability between providers and insurers, and more attention on directing and properly covering services for Medicare- and Medicaid-eligible patients enrolled in MA plans; the addition of plan denial rates to the Medicare Compare site as a plan selection tool; and a floor for payments, which seem to press ever lower when it comes to skilled nursing per diems.
But while tackling additional changes, Fallon raised alarm bells about MA plan compliance with current rule implementation. While 2024 changes that were finalized earlier this year require plans to change how they handle pre-authorizations and determine coverage, many, she said, don’t appear too flustered by the new requirements.
“Plans don’t seem worried about them, which to me means, they ain’t doing nothing different,” she said, adding that advocates are pressing CMS to issue subregulatory guidance on those roles to better spell out just what plans are supposed to (and can no longer) do.
“We’re hopeful that the subregulatory guidance is going to really put a little more meat on the bones and really make the plans comply,” she said. “We’re still pushing for all of that, and lots of work left to do, but I’m optimistic about where we’re headed.”
After the depressing score that has accompanied nursing homes’ MA journey so far, that optimism must come as music to providers’ weary ears.
Kimberly Marselas is senior editor of McKnight’s Long-Term Care News.
Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.