From Healthcare Innovation:
Nearly a year has passed since Donald Berwick, M.D., and Rick Gilfillan, M.D., opened a full-frontal attack on Medicare Advantage (MA), in their September 30, 2021 blog in Health Affairs online entitled “Medicare Advantage, Direct Contracting, And the Medicare ‘Money Machine.’” That blog, which was actually the second of a two-part blog set, but was the one that captured nearly all the public attention, and indeed, it created a firestorm in federal healthcare policy circles.
As we reported in a news article on that date, Dr. Berwick, who had served as Acting Administrator of the Centers for Medicare and Medicaid Services (CMS) from July 2010 to December 2011, and Gilfillan, who had served a stint as Deputy Administrator of the Centers for Medicare and Medicaid Services and Director of the Center for Medicare and Medicaid Innovation from 2010 to 2013, had “criticized in the very strongest terms the new Direct Contracting program under Medicare, the ongoing evolution of the Medicare Advantage program, and some core aspects of the ways in which accountable care organizations (ACOs) are managed in the Medicare Shared Savings Program (MSSP).” They essentially asserted that any financial incentive was fundamentally wrong and damaging to the ideals of the Medicare program and of true value-based contracting.
A number of industry leaders jumped in to make their points, among them Don Crane, who at that time was president and CEO of APG, America’s Physician Groups, an association that represents many of the most advanced multispecialty physician groups in the country. As we reported last September 30, “APG’s Crane wrote in his letter to HHS Secretary Becerra on Thursday that “In their materials, Drs. Berwick and Gilfillan suggest that CMS replace the HCC RAF [risk adjustment factor] scoring process in two years and begin a process to develop an approach that does not rely on provider reporting. They claim this is necessary because of significant MA “overpayment” they attribute to risk score inflation through risk adjusted coding. Risk adjustment,” Crane emphasized, “was designed to estimate a beneficiary’s future health care costs and align compensation with acuity and severity of disease and the related costs of care as complex patients require the use of more resources. Risk adjustment encourages the enrollment of the sickest patients, and those in a lower socioeconomic status and is widely used in MA and the Medicare Shared Savings Program (MSSP) to appropriately risk adjust quality, expenditure benchmarks, and cost metrics, allowing for a more precise measurement of performance. Alignment of payment and performance goals rewards coordinated care and enhances the achievement of improved health and care among all individuals.”
Fast-forward to summer of this year, and last month, another team of policy leaders has leaped into the discussion. In their July 8 opinion article in Health Affairs online, entitled “Making The Right Diagnosis: A Response To Berwick And Gilfillan,” Jeffrey Kang, M.D., M.P.H., Ian Duncan, Ph.D., and Nhan Huynh, Ph.D., walk their readers through a complex set of propositions, concluding that Berwick and Gilfillan, in their view, miss the point altogether. As they write, “The subsequent debate on the flaws or virtues of MA and capitation shifts the focus from the underlying problem, relatively higher payments in MA versus TM [traditional Medicare] and their cause, and thus fails to provide a meaningful solution. If the relatively higher payments were to go away then MA plans would compete with TM on a level playing field, the original Congressional intent for the two programs. We will therefore respond to the coding and risk adjustment issues raised in the original Berwick and Gilfillan posts, in particular focusing on the root cause of the higher payment, the rationale for disease-based risk adjustment, and a potential solution.”
Indeed, these experts write, “We agree that there is evidence for higher payment to MA plans relative to TM. What is unclear is whether this is due to an overcoding problem in MA or an undercoding problem in TM. The incentive in MA is for physicians to code comprehensively for diagnosis (using International Classification of Diseases (ICD) codes, specifically ICD-10 codes); the incentive in TM is for physicians to code procedures (using Current Procedural Terminology (CPT) codes).”