Expert RFI Responses with Potential to Improve Medicare

Over the past few months, Congress and the Department of Health and Human Services (HHS) have issued a wave of new health care-related requests for information (RFIs). These RFIs come at a time when the country is shifting to address deficiencies in the health care system COVID helped to expose. The requests provide an opportunity for health policy experts to weigh in on a range of topics – from strengthening primary care to improving Medicare Advantage. In the coming months, additional RFIs are expected on changes to the Medicare and CHIP Reauthorization Act (MACRA) and establishing a National Provider Directory.As organizations begin publishing their responses to the Medicare Advantage and primary care RFIs, we have compiled some of the top themes that have emerged over the past few months with the potential to improve care for Medicare patients.

Medicare Advantage RFI

In August 2022, the Centers for Medicaid & Medicare Services (CMS) distributed an RFI seeking ways to improve Medicare Advantage through advancing health equity, broadening access, enhancing person-centered care, supporting affordability, and engaging partners. This RFI comes as Medicare Advantage enrollment is growing and will soon surpass traditional Medicare enrollment, largely because of its lower premiums and additional benefits. Recent studies have found concerning evidence of Medicare Advantage’s prior authorization requirement leading to delays or denials in medically necessary patient care. The cost of the program itself also continues to rise substantially.Many organizations responded to this RFI, and several distinct ideas rose to the top:

• Increase oversight of prior authorization. While prior authorization was originally intended to reduce medical spending, it has become a barrier to care for some patients. In response, the House recently passed legislation to increase CMS’ oversight on prior authorization and expediate the approval process. An increase in CMS oversight over Medicare Advantage plans’ use of prior authorization is likely ensure faster access to needed care.

• Expand benefits and collect data to advance health equity. The growing Medicare Advantage population is becoming more diverse and has greater health-related social needs. Historically, some studies have found that Medicare Advantage plans exacerbate barriers to care, as evidenced by trends in sicker patients disenrolling from Medicare Advantage and switching to traditional Medicare. Responses to this RFI include several recommendations for solving this issue, including the expansion of benefit flexibility to address social determinants of health and additional data collection requirements to help determine whether supplemental benefits available to all Medicare Advantage members equitably.

• Solve for the imbalance between Medicare Advantage and traditional Medicare. It would be remiss to leave traditional Medicare out of the conversation around improving Medicare Advantage, since it can have such a significant impact on the overall program. As the Center for Medicare Advocacy’s RFI response said, there is now an “imbalance” between the two programs due to coverage expansion and additional benefits offered through Medicare Advantage, but not through traditional Medicare. To re-balance the scales and ensure robust care with strong health outcomes for all Medicare beneficiaries, CMS could consider bolstering traditional Medicare by expanding member benefits and establishing out-of-pocket maximums, at a minimum.

To read the full responses, visit the links below:

• Academy of Managed Care Pharmacy (AMCP)

• AHIP

• Center for Medicare Advocacy

• Health Care Transformation Task Force

• National Health Council

• Regulatory Relief Coalition (RRC)

• USC-Brookings Schaeffer Initiative for Health Policy

Primary care RFI

In late June 2022, the Office of the Assistant Secretary for Health (OASH) within HHS posted an RFI asking health care professionals and policy experts for recommendations to improve the primary health care system.Many primary care providers are struggling with workforce shortages, burnout, and financial instability from COVID, and now, inflation. HHS said it plans to use the RFI responses to inform its strategic plan for supporting and advancing primary health care.In reviewing the responses to this RFI, a few central issues included:

• Expanding the primary care workforce. The health care workforce is shrinking – and physicians are facing continual turnover. Medical students are opting for specialist professions with higher pay. In general, an improved provider payment system is needed for primary care practices in relation to specialists. While the RFI responses differed on the specifics -- from increasing payment rates to investing in programs that encourage providers to enter the primary care field -- all agreed something needs to be done to incentivize and expand the workforce to keep up with demand.

• Integrating behavioral health. The need for behavioral health services has grown during the pandemic, but many mental health care providers do not accept Medicare, Medicaid, or other types of insurance. As a result, too many patients are forced to pay out of pocket or skip the services altogether. The urgent need to effectively integrate behavioral health services with primary care and increase reimbursement for behavioral health specialists has come into greater focus. The pandemic provided important lessons regarding the efficacy of telehealth as a means of ensuring access to care. These lessons should inform policymaking on a broad scale going forward to address longstanding barriers in accessing care because patients don’t have the means to travel to physical offices or there is not a practice available in their area. The United States of Care’s RFI response outlined how enhancing telehealth technologies could help address those barriers.

• Increasing health equity resources. The Biden administration has said health equity is a top priority for improving quality and access to care across the country. Many providers, however, are not equipped to conduct broad-based screenings for social needs or other similar initiatives. Additionally, if funding is not available for organizations that provide the necessary social supports, providers are limited in their ability to direct patients to the help they need. Community-based organizations providing social services should receive sustainable and predictable revenue streams to ensure patients can access the resources needed to improve long-term health outcomes.

To read the full responses, visit the links below:

• Association of American Medical Colleges (AAMC)

• Aurrera Health Group

• The Commonwealth Fund

• National Committee for Quality Assurance (NCQA)

• United States of Care

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Erin Connolly [Senior Policy Consultant]