Insurers bridle over Medicare transparency push

Jun 04, 2024

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Driving The Day

A page from the 2019 U.S. Medicare Handbook is displayed.

Providers want CMS to require more transparency from Medicare Advantage plans. | Pablo Martinez Monsivais/AP

TRANSPARENCY DISADVANTAGE? As Medicare Advantage comes under scrutiny, insurers are bristling at expanding some transparency measures that providers have pushed for in the program.

The context: Medicare’s private sector alternative has come under bipartisan fire in Congress for care denials and estimates of substantial overpayment to the plans. Some lawmakers are also concerned about the use of artificial intelligence in the prior authorization process. Insurers have countered that prior authorization can curb unnecessary spending and low-value care.

The concerns come as Medicare Advantage enrollment has grown to include more than half of Medicare beneficiaries.

Earlier this year, CMS requested information about how the program can be more transparent, with a focus on data and increasing competition.

In response to the request, provider groups like the American Medical Association and the American Hospital Association called for the agency to enact more transparency requirements surrounding the prior authorization process and MA plans’ use of AI in care decisions. They also called for additional scrutiny of consolidation among plans.

The AHA called for “clear and transparent standards” on “auto-denial software” that would also require MA plans to disclose AI use in claims decisions to the public. The Medical Group Management Association pushed for "more granular" data on prior authorization in the program.

“Use of automated decision-making systems that determine coverage limits, make claim determinations, and engage in benefit design should be publicly reported,” the AMA wrote.

Plans’ take: Medicare Advantage insurers broadly agreed that transparency is important but had some concerns.

Insurer lobbying group AHIP argued that CMS shouldn’t consider more reporting requirements around processes that determine medical necessity, saying substantial requirements are already in place, pointing to new regulations requiring plans to report prior authorization metrics. AHIP also called for CMS to allow “appropriate” context around those metrics and said AI can help simplify and expedite claims processing.

“Prior authorization metrics without appropriate context or explanations … may be misinterpreted,” AHIP wrote, saying its members are committed to “safe, transparent, explainable, and ethical” AI use.

The Better Medicare Alliance, which represents MA insurers, called for CMS to gather standardized data surrounding supplemental benefits. But it said the agency should “leverage current data collections and capabilities” and explore ways to “consolidate or streamline data collection.” It didn’t directly address prior authorization.

UnitedHealth Group called on CMS to facilitate “more transparent comparisons” between MA and traditional Medicare and provide more transparency surrounding the Medicare Payment Advisory Commission’s estimates. UHG also called for the agency to boost its data capabilities to “ensure efficiency” in areas including prior authorization.

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America’s seniors need our help – now. The Administration’s federal staffing mandate will force more nursing homes to close and displace hundreds of thousands of residents. Nursing homes need targeted investments, not blanket mandates. Learn more about our workforce solutions.

In Congress

Anthony Fauci testifies on Capitol Hill.

Anthony Fauci faced questions from a House subcommittee Monday about Covid's origins. | Francis Chung/POLITICO

FAUCI GOES ON DEFENSE — Dr. Anthony Fauci defended his actions during the Covid-19 pandemic before House lawmakers Monday and distanced himself from an aide accused of misconduct, POLITICO’s Carmen Paun reports.

Fauci pushed back on claims by Republicans on the House Select Subcommittee on the Coronavirus Pandemic that he tried to squelch the theory that the virus spilled over from a lab in Wuhan, China.

Fauci said the theory isn’t a conspiracy theory and has kept an open mind on the pandemic's origins but has endorsed a theory that the disease came from an animal.

He said the research his agency funded at the lab couldn’t have created Covid. HHS has stripped the EcoHealth Alliance, the U.S. research group that collaborated on virus studies with Wuhan, and its president of federal funding.

About the aide: Democrats and Republicans on the panel recently blasted longtime Fauci adviser David Morens, who HHS put on leave for using personal email for official business. Emails the subcommittee released last month show Morens trying to shield correspondence.

In his first public Capitol Hill testimony since leaving the federal government, Fauci said Morens wasn’t part of his inner circle.

“Despite his title, and even though he was helpful to me in writing scientific papers, Dr. Morens was not an adviser to me on institute policy or other substantive issues,” Fauci told lawmakers.

THE WEEK AHEAD — Congress is slated for a busy but short week with plenty of health care action, including a planned vote on contraception Wednesday in the Senate.

Here’s what we’re watching:

— A House Energy and Commerce subcommittee meets Tuesday for an oversight hearing on potential reforms to the 340B drug discount program.

— A House Natural Resources subcommittee meets Tuesday for a legislative hearing that will address a bill that would require the Interior Department to consult HHS on decisions about critical minerals and materials that could impact health care.

— The Senate HELP Committee meets Tuesday for a hearing on “the assault on women’s freedoms,” including abortion access.

— The House Veterans’ Affairs Committee meets Tuesday to examine the VA’s “improper decision” to give senior executives “millions in incentives.”

— The Senate Aging and Veterans' Affairs committees hold a joint hearing Wednesday on bolstering services for veterans and caregivers.

— The Senate Homeland Security and Governmental Affairs Committee meets Wednesday to examine harmonizing federal cybersecurity regulations.

PUSH TO LET HOUSE DOCS PRACTICE — Members of the House are allowed to have limited work outside of their official duties in office, but lawmakers who are doctors and dentists are virtually prevented from doing their jobs, a prohibition Republican leaders are again trying to change.

House Republicans have tacked on a provision in spending bills that would allow the lower chamber’s medical providers to work outside of Congress like other members, with a typical cap of $30,000 in annual income, POLITICO’s Jennifer Scholtes reports.

Democrats aren’t in favor. Top Democratic appropriator Rep. Rosa DeLauro (D-Conn.) said the proposal would create “loopholes” for outside work and potential “conflicts of interest.”

Anesthesiologist and top House appropriator Rep. Andy Harris (R-Md.) said he hopes “everyone wants health care professionals to maintain their skills.”

“Not everybody’s in Congress forever,” he said.

THE GOLD STANDARD OF HEALTHCARE POLICY REPORTING & INTELLIGENCE: POLITICO has more than 500 journalists delivering unrivaled reporting and illuminating the policy and regulatory landscape for those who need to know what’s next. Throughout the election and the legislative and regulatory pushes that will follow, POLITICO Pro is indispensable to those who need to make informed decisions fast. The Pro platform dives deeper into critical and quickly evolving sectors and industries, like healthcare, equipping policymakers and those who shape legislation and regulation with essential news and intelligence from the world’s best politics and policy journalists.

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AROUND THE AGENCIES

HUGE MOMENT FOR ECSTASY — An FDA panel of expert advisers is set to decide today whether to recommend that the agency approve the use of MDMA, the scientific name for ecstasy, for post-traumatic stress disorder, POLITICO’s Erin Schumaker reports.

A green light from the FDA could open the door to significant changes in psychedelic medicine and for veterans and all Americans with mental illness. A red light would upend a burgeoning industry — and crush a lot of hopes.

Lykos Therapeutics, whose application the FDA panel will consider, makes the case that MDMA can help combat PTSD, which afflicts many veterans. VA officials and members of Congress have been bullish on the treatment, which has shown striking results in trials.

Skepticism abounds: Lykos has come under fire for allegedly slanting its studies to make the case for approval. The Institute for Clinical and Economic Review, a research group, said in March that it has “substantial concerns” about the results. ICER also said the psychedelic community treats psychedelics “more like a religious movement than like pharmaceutical products,” feelings the report said “were sometimes inculcated in patients participating in the trials.”

The head of the National Institute on Drug Abuse, Nora Volkow, last month compared the hype for psychedelics as a cure for mental illness to belief in “fairy tales” in Senate testimony.

MENTAL HEALTH WAIVERS GRANTED — Ten states have joined a Medicaid demonstration that gives them funding to offer around-the-clock mental health and substance use treatments at mental health clinics, Chelsea reports.

Alabama, Illinois, Indiana, Iowa, Kansas, Maine, New Hampshire, New Mexico, Rhode Island and Vermont will receive Medicaid funding to offer comprehensive services at Certified Community Behavioral Health Clinics, joining 10 other states. States must submit Medicaid waivers to participate, offer the crisis services 24/7 and serve all patients, regardless of their ability to pay.

The move comes amid a growing mental health and substance-use disorder crisis.

A message from the American Health Care Association:

Names in the News

Marisa Aleguas is joining the National Oceanic & Atmospheric Administration as a speechwriter and adviser to NOAA Administrator Rick Spinrad. She was previously a speechwriter at HHS.

Jennifer Laudano, previously of the National Academy for State Health Policy, has joined Arnold Ventures as vice president of health care advocacy. Andrew Bacher-Hicks, previously of Boston University, has also joined Arnold Ventures as vice president of evidence and evaluation.

JOIN US ON 6/13 FOR A TALK ON THE FUTURE OF HEALTH CARE: As Congress and the White House work to strengthen health care affordability and access, innovative technologies and treatments are increasingly important for patient health and lower costs. What barriers are appearing as new tech emerges? Is the Medicare payment process keeping up with new technologies and procedures? Join us on June 13 as POLITICO convenes a panel of lawmakers, officials and experts to discuss what policy solutions could expand access to innovative therapies and tech. REGISTER HERE.

WHAT WE'RE READING

The San Francisco Chronicle reports on bird flu being detected for the first time in California in wastewater.

Modern Healthcare reports on “uneven” enforcement of hospital staffing laws between states.

A message from the American Health Care Association:

America’s seniors need our help – now.

The Administration’s federal staffing mandate will worsen the ongoing labor crisis in nursing homes, forcing more facilities to downsize or close.

Hundreds of thousands of residents will be displaced – and seniors’ access to care restricted – if lawmakers fail to act.

An unfunded mandate won’t create more caregivers. Congress: Protect seniors’ access to care – before it’s too late.

Learn more about the issue.