Reprinted with AIS Health permission from the June 18, 2020, issue of RADAR on Medicare Advantage
As protests erupt across the U.S. calling for racial justice and police reforms, the COVID-19 pandemic continues to bring to light many of the racial disparities in health care, putting pressure on policymakers and the industry to take a hard look at health and access inequities. Meanwhile, a new report from CMS indicates that racial disparities are widening in Medicare Advantage, and experts suggest one way for plans to address those would to be to make immediate investments in their provider networks.
“You see some very consistent themes in that report around inadequate provider networks in vulnerable minority communities. And those findings are only going to worsen in the middle of this pandemic when you consider that providers as small businesses are extremely vulnerable because of fluctuations in their revenues,” says John Gorman, chairman and CEO of Nightingale Partners LLC, the first Opportunity Zone fund dedicated to making major investments in social determinants of health with MA and Medicaid plans.
For the fifth year in a row, CMS’s Office of Minority Research in April quietly released a stratified report highlighting the racial and ethnic differences in health care experiences and care of MA enrollees. Conducted in partnership with RAND Corp., the report analyzed patient-reported data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and clinical quality data from the Healthcare Effectiveness Data and Information Set (HEDIS) on which the CMS star quality ratings system is largely based. Like last year’s report, it compared differences in care on seven patient experience and 44 clinical care measures.
In 2018, an estimated 69.3% of all MA beneficiaries were white, 13.4% were Hispanic, 10.7% were black and 4% were Asians or Pacific Islanders (API), according to the report. As of February 2018, nearly 21.08 million Medicare beneficiaries were in an MA plan.
The new data showed that black members enrolled in MA plans in 2018 received worse clinical care than white enrollees on 20 out of 44 measures, similar care for 20 and better care for four. This was compared to the previous year’s findings that black enrollees in 2017 received worse clinical care than white members for 14 measures but received similar care quality for 16 and better quality for three. And the findings for Hispanic beneficiaries were similar: they received worse clinical care than white beneficiaries for 19 measures and similar care for 18 measures.
By contrast, API beneficiaries in 2018 received worse clinical care than white members for just six measures and better clinical care for 15 measures. And while all minority populations reported experiences with care that were either worse than or similar to the experiences reported by white enrollees, American Indian or Alaska Native (AI/AN) and API beneficiaries reported worse patient experiences than white beneficiaries on a majority of measures. Both API women and men reported receiving worse care than whites on six measures: getting needed care, getting appointments and care quickly, customer service, doctors who communicate well, care coordination, and getting needed prescription drugs. One exception was that they were more likely than white enrollees to receive their annual flu vaccine. Black and Hispanic populations, meanwhile, reported receiving worse care relating to the flu and getting appointments and care quickly.
Report Raises Red Flag About Networks
Not getting the proper care when it’s needed is a reflection of the provider network, suggests Gorman. “And then when you look at the clinical measures where there’s huge racial disparities, all of those tie back to a lack of culturally competent physicians serving these populations in a manner that speaks to the way that they need to access health care,” he observes. “And anything from BMI [body mass index] to smoking cessation counseling or getting flu shots — all those things have to be handled very differently when you’re dealing with an African American or a Latino or an Asian population.
“This report just sent a chill up my spine that we are about to watch already inadequate provider networks serving minorities get a lot worse,” he continues. “This all speaks to an urgent crisis in network adequacy in underserved communities that could have a crippling effect on star ratings for MA plans serving those communities.”
“We really need to think as an industry hard about, how do we shore up provider networks in medically underserved communities with docs who are culturally competent to the population you’re serving?” adds Gorman. And he says he doesn’t think telehealth is the answer. “In fact, what works far better with vulnerable minority populations rather than telehealth is more mobile health and the whole idea of house calls and bringing the physician and the provider into a home and community-based setting.”
Pandemic May Worsen Provider Shortage
John Weis, President and Co-Founder of Quest Analytics, LLC, which assists MA plans in building provider networks, predicts that “there will be a significant impact on practice consolidation” from the pandemic. “Given the potential risk to providers, we predict that coming out of COVID, we’ll see an uptick in providers that want to minimize their exposure and consider retirement.” An estimated 50% of providers were over age 55 as of 2018, and “as more providers reach retirement age, how they care for themselves and their population could mean fewer providers available to practice in person, or practice at all,” he suggests. “This heightens the importance of the plans’ need to understand in detail, both the adequacy of their network along with the accuracy of their provider directory. With fewer providers available, if plans are not prepared, this will drive both out-of-network utilization and increase health care costs in rural areas.”
Asked whether these network adequacy issues could lead to penalties, Weis says his hope is regulators will be more flexible given the pandemic and will err on the side of having plans submit corrective action plans rather than fines. “I also think they would be hesitant to ‘disapprove’ a health plan because they need as many options in the market as possible, so again, I think they may work with the plans that are having trouble finding providers due to COVID shortages, rather than disapprove a filing,” Weis adds.
CMS: Data Informs Quality Improvement
The CMS report concluded that “quality improvement efforts should focus on enhancing clinical care for Black and Hispanic beneficiaries and investigating differences between the experiences of AI/AN and API beneficiaries as compared with those of White beneficiaries.” The agency added that this information “may be of interest” to MA organizations and Part D sponsors as they “consider strategies to improve the quality of care received by racial and ethnic minorities and reduce disparities.”
A CMS spokesperson tells AIS Health the agency recommends MA plans take many of the same steps outlined in the CMS Equity Plan for Improving Quality in Medicare, which was released in 2016. These efforts include collecting and analyzing data on race, ethnicity, sex, disability status and primary language, and developing and implementing promising approaches to reducing health disparities.
The spokesperson added that CMS has other resources available that could be used to identify and address disparities and target quality improvements. These include: the Mapping Medicare Disparities Tool (an interactive map that helps identify areas of disparities among Medicare beneficiaries in health outcomes, utilization, and spending and compares hospitals on quality and cost of care); the Rural-Urban Disparities in Health Care in Medicare Report that describes rural-urban differences in health care experiences and clinical care by race and ethnicity; the Minority Research Grant Program that supports researchers at minority-serving institutions exploring the health care needs of vulnerable populations; and the Health Equity Technical Assistance team that helps guide MA organizations into action to address health disparities among those they serve.
Plans Have Tools, Lack Incentives
Dan Mendelson, founder of Avalere Health, suggests that while MA plans have the tools to address racial disparities, they don’t necessarily have the incentives to prioritize them. “I think Medicare Advantage plans are uniquely equipped to measure, understand, identify and mitigate disparities because the plans know the health care history of the beneficiary, they know the race, they know the location of the individual, they know their issues. So, a proactive form of engagement that is focused on disparities can work,” Mendelson suggests to AIS Health. “And in some ways, I think MA is a great setup through which to address these issues.
“In addition, the plans already have broad flexibility in their benefit design to deliver all sorts of services that are not covered in traditional fee for service. You have home visits, food delivery, and the ability with [expanded supplemental benefits] to do pest control in the house. So, the framework is there [to address disparities]. One thing that is not there at this point is any kind of direct incentive to the plans to act, and one thing that we’ve found with quality has been once you start associating payment with an outcome, plans kick into gear.”
Whether it’s through new calculations in the star quality ratings or a separate system to determine plan bonuses (or penalties), effectuating major change is going to take years, suggests Mendelson. “The literature shows that there are effects of income and various covariates, but there is kind of a persistent gap that exists for very complex reasons, and if people of color do not trust the medical care system, it’s going to take work and time to overcome that.”
One thing CMS could do in the short term is begin “measuring and reporting immediately and starting to talk about the kinds of actions that they expect plans to take to eliminate disparities,” he adds. “For example, a lot of plans engage beneficiaries in an annual wellness visit in MA, and there could be additional screening or conversations or other kinds of interventions for black and Latino populations that could be something that would be helpful in starting to close gaps.”
Gorman suggests that plans consider providing debt relief to physician groups, especially minority provider practices that are struggling financially, “for working capital or expansion.” And they should consider reimbursing practices above Medicare and Medicaid rates. “If this is all that stands between you and a failing grade on network adequacy, then it’s damn worth the investment. This is absolutely an issue where throwing money at the problem is called for and you’ve got to make it worth their while, for especially minority residents to come and practice in these communities and then stay once they’re done with residency.”
Meanwhile, a new study by researchers at the MIT Sloan School of Management backs up other research showing that black patients and elderly people are more likely to die from COVID-19 than white patients and people under the age of 65, but rules out certain factors. Looking at daily county-level COVID-19 death rates from April 4 to May 27, the statistical analysis controlled for patients’ income, weight, diabetic status and smoking status and concluded that none of those factors were driving the positive correlation between death rates and the “alarming” share of black Americans impacted, explains Christopher Knittel, the George P. Schultz Professor of Applied Economics at MIT Sloan.
“It has to be something else that’s not in the model, so that’s I think helpful for policymakers because it allows them to [home in] on some potential causes and not necessarily waste time on other causes that we can eliminate,” suggests Knittel, who co-authored the study. “We also controlled for uninsurance, so I think if you start eliminating the things in our model that it can’t be, and this is speculation but something policymakers can consider, it might be the quality of insurance or the quality of hospital care…it could be something cultural, but those are the types of factors that policymakers and health professionals should be looking into.”
The study did, however, find that those who commute via public transportation are more likely to die from COVID-19 relative to those who telecommute, adds Knittel.
View the CMS report at https://go.cms.gov/2N3qKi6.
Contact Gorman at email@example.com, Knittel via Paul Denning at firstname.lastname@example.org, Mendelson at email@example.com or Weis via April Beane at firstname.lastname@example.org.