It’s been almost a year since Donald Berwick, MD, and Rick Gilfilan, MD, launched their frontal assault on Medicare Advantage (MA) in their September 30, 2021 blog. health problems An online blog titled “Medicare Advantage, Direct Contracts, and the Medicare ‘Money Machine'”. This blog was actually his second in a two-part set of blogs, but it was the one that got almost all the public attention. It caused an uproar in federal health policy circles.

Dr. Berwick, who served as acting administrator of the Centers for Medicare and Medicaid Services (CMS) from July 2010 to December 2011, and Mr. Gilfilan, who served as deputy administrator, as reported in a news story of the day. Director of the Center for Medicare and Medicaid Services and Director of the Center for Medicare and Medicaid Innovation from 2010 to 2013 said, “The new direct contract program under Medicare, the ongoing evolution of the Medicare Advantage program, and several They criticized in very strong terms: a core aspect of how Accountable Care Organizations (ACOs) are managed in the Medicare Shared Savings Program (MSSP).” It is technically wrong and undermines the ideals of the Medicare program and true value-based contracts.

Many industry leaders jumped in and voiced their opinions. Among them was Don Crane, then president and CEO of America’s Physician Groups, APG, an association representing many of the nation’s most advanced multidisciplinary physician groups. As we reported on September 30 last year, “APG Crane wrote on Thursday in a letter he sent to HHS Secretary Becerra: We are proposing to replace the RAF. [risk adjustment factor] Within two years, we will initiate a scoring process to develop a provider-report-agnostic approach. They argue that this is necessary because of the significant MA “overpayment” resulting from risk score inflation due to risk adjustment coding. It is designed to adjust disease severity and severity, and associated medical costs and coverage, because the sickest patients need to use more resources. Encourages enrollment of patients with lower socioeconomic status and is widely used in MA and Medicare Shared Savings Programs (MSSPs) to better risk-adjust quality, spending benchmarks, and cost metrics to enable more accurate results to Performance measurement. Aligning payment and performance goals rewards coordinated care and enhances achievement of improved health and care for all individuals. ”

Fast forward to this summer, and last month another team of policy leaders jumped into the discussion. In their July 8 Opinion article, health problems On-line entitled Making The Right Diagnosis: A Response To Berwick and Gilfillan, Jeffrey Kang, MD, MPH, Ian Duncan, Ph.D., Nhan Huynh, Ph.D. walks readers through a series of complex propositions. doing. , conclude that, in their view, Berwick and Gilfiran miss the point entirely. As they write, “subsequent discussions about the drawbacks or virtues of MA and capitation have shifted focus away from a potential problem: the relatively high payouts of MA and TM. [traditional Medicare] And we can’t find out the cause and provide a meaningful solution. If the relatively high payouts were to go away, MA’s plan would compete with TM on a level playing field, which was Congress’ original intention for her two programs. As such, it addresses the coding and risk adjustment issues raised in the original Berwick and Gilfilan posts, and specifically addresses the root causes of higher payouts, the rationale for disease-based risk adjustment, and potential solutions. focus. ”

In fact, these experts write: It is unclear whether this is due to MA overcoding problems or TM undercoding problems. The incentive for MA is for physicians to code comprehensively for diagnosis (using International Classification of Diseases (ICD) codes, specifically his ICD-10 code). The incentive for TM is for the physician to code the procedure (using the Current Procedural Terminology (CPT) code).

These authors have important qualifications to bring into the discussion. The article states, “Jeffrey Kang, MD, MPH developed the original disease-based risk-adjusted model, Hierarchical Condition Categories (HCC). Ian Duncan, Ph.D., FSA FIA FCIA FCA CSPA MAAA, is an adjunct professor of actuarial statistics at the University of California, Santa Barbara, and a medical forecaster. Principal of modeling and actuarial services provider Santa Barbara Actuaries Inc. Dr. Duncan holds a degree in Economics from Balliol College, Oxford and holds a Ph.D.Herriot Watt, Edinburgh, Scotland. Graduated with a PhD in Statistics.He is a Fellow of many actuarial associations.He is active in public policy and health care reform and served on the Board of the Massachusetts Health Insurance Connector Authority from 2007 to 2014. Dr. Nhan Huynh is also a board member of the Society of Actuaries (2012-5) and currently serves as the Chair of Research Executive for SOA Dr. Nhan Huynh is a consultant at Santa Barbara Actuaries Inc.

Kang, Duncan, and Huynh write: Policy makers should address the underlying incentives associated with coding instead of abandoning disease-based risk adjustments. The correct short-term solution is to adjust the MA coding strength to be relatively high. In the medium term, instead of abandoning disease-based risk adjustment in MA, CMS should introduce disease-based risk adjustment in TM. This will not only (a) address differences in coding strength between MA and TM, but also (b) better direct resources to providers caring for patients with medical conditions within TM. And in the long term, “Once the two programs are on par (i.e. have similar incentives to obtain diagnostic codes), we will be able to use both programs to account for patient differences.” It would be appropriate to consider improving the risk adjustment,” they wrote. For example, in both functional status and social determinants of health (SDOH). ”

The authors look directly at Berwick and Gilfiran’s claim that Medicare Advantage inevitably encourages diagnostic code creep, suggesting that traditional Medicare has correct diagnostic coding. However, as Kang, Duncan, and Huynh point out, traditional Medicare explicitly reimburses based on unit of work rather than patient complexity, a reality that is inherently distorting. claim to be helping. they wrote: [congestive heart failure], diabetes with nephropathy, and peripheral vascular disease. Let’s say a patient sees him three times a year. On MA, this patient has all three diagnoses coded in her three visits, but two interim visits and she has the same CPT code in one short-term visit in her three visits. can be used for hospital visits. Conversely, in TM, the same patient is coded for her 1 comprehensive visit and her 2 interim visits, but only the diabetic diagnosis is submitted. At MA, the physician has an incentive to pinpoint all three of her diagnoses, including complications (diabetes with nephropathy attracts her HCC score higher than diabetes itself). With TM, a doctor is paid based on her CPT code, regardless of the diagnosis on record. Therefore, it is more likely that the same patient’s diagnostic code will be undercoded in TM but overcoded in MA. ”

After walking readers through the very complexities of comparing Medicare Advantage and traditional Medicare incentives, the authors write: If MA plans are encouraged to “skim health” and plans that experience adverse selection are underpaid, CMS will be able to address coding intensity issues and continue to migrate to physician-reported encounter data. , we believe we can use existing tools. ” And they wrote: I can imagine a world where it doesn’t matter if a doctor practices her FFS, or supervised care, or both. All physicians are incentivized to accurately and fully code diagnoses, care for all complex patient conditions, and provide appropriate reimbursement according to the patient’s burden of disease. ”