HealthCare Roundtable e-News – October 23, 2023

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Top News

CMS Releases 2024 Medicare Advantage and Part D Star Ratings

The Centers for Medicare and Medicaid Services (CMS) released (data here) 2024 Star Ratings for Medicare Advantage (MA) and Part D plans (PDPs). Star Ratings are released annually and reflect the experiences of individuals enrolled in MA and Part D plans, where plans are rated on a one to five star scale on various measures of performance. The release comes ahead of Open Enrollment, which begins on October 15.

Key results include:

  • The overall rating for Medicare Advantage with Part D (MAPD) contracts for 2024 was 4.04, and 3.11 for PDPs. Notably, this represents a significant decrease from 2023, in which the average was 4.14 for MAPD contracts and 3.25 for PDPs. In 2022, MAPD and PDP contract performance was 4.37 and 3.70 respectively, and in 2021, it was 4.06 and 3.58 respectively.
  • Approximately 42% of MAPD contracts earned 4 stars or higher for 2024, which comprise 74% of MAPD enrollees. Approximately 27% of PDPs received 4 stars or higher, comprising 2% of PDP enrollees.
  • Compared to 2023, there was a significantly lower percentage of MAPD contracts with 5 stars.

The significant decrease in Star Ratings can be attributed to several key methodology and policy changes that are occurring in 2025. Most notably, CMS began applying the long-awaited Tukey fence outlier deletion methodology. The Tukey method identifies certain outliers from the performance data and removes these outliers prior to developing the cut point for Star Ratings. Outliers are more commonly found at the low end of performance, and thus application of this methodology likely translates into lower Star Ratings performance.

Other key methodology changes in 2024 Star Ratings include:

  • The disaster policy was modified to include data integrity issues in the definition of missing data, such that disaster-affected contracts with a data integrity issue on a given measure received the final measure rating from the current year.
  • The weight for the Part C Controlling Blood Pressure measure was increased to 3.
  • Re-specified Part C Plan All-Cause Readmissions measure moved into the 2024 Star Ratings as a new measure with a weight of 1 for the first year.
  • The Part C Transitions of Care measure was added to the 2024 Star Ratings with a weight of 1.
  • The Part C Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions measure was added to the 2024 Star Ratings with a weight of 1.

In addition, there were several key policy changes that occurred during 2023 Star Ratings that are also important to note, given their continued impact in 2024 Star Ratings:

  • Patient experience and access Star Ratings (e.g., CAHPS measures) increased in weight from 2 to 4. Note that beginning with 2026 Star Ratings, CAHPS measure weights will reduce back down from 4 to 2.
  • New guardrails restricting upward and downward movement of a measure’s cut points for certain measures were implemented.
  • Several COVID-19 flexibilities were phased out. In particular, the disaster policy enabled plans to pick the higher of their 2021 or 2022 Star Ratings for 2022. Difficulties in collecting certain data elements during the COVID-19 pandemic also influenced Star Ratings during this time.

 

KFF Survey Shows New Trends in Employer-Sponsored Health Insurance Coverage

The Kaiser Family Foundation’s 25th annual Employer Health Benefits Survey of over 2,100 small and large employers has identified new trends in employer-sponsored health insurance. In 2023, annual family premiums increased by 7%, reaching $23,968, in line with wage and inflation increases. Workers at large companies contribute $6,575 annually to family premiums, with expectations of further increases, while those at small companies pay around $2,500 more. Deductibles have risen by 10% since 2018, with employees of small companies facing larger deductibles than their counterparts at larger firms. The recent Supreme Court decision reversing Roe v. Wade has posed challenges for large employers with employees in multiple states, as different states adopt varying abortion laws. Among large firms, 10% do not cover abortion under any circumstances, 18% only cover it in limited cases, 32% cover it in most or all cases, and 40% are uncertain due to evolving policies. Some offer financial travel assistance for beneficiaries requiring out-of-state abortions. The survey also highlighted shortcomings in mental health and substance use networks. Only 59% of large employers report having adequate mental health providers, and 58% say the same for substance use condition providers for timely access and care. While 18% of large employers expanded their mental health provider networks, 21% limited coverage.

 

House Energy and Commerce Committee Hosts Legislative Hearing Examining Physician Reimbursement Models and the Medicare Physician Fee Schedule

The House Energy and Commerce Committee convened a hearing titled “What’s the Prognosis?: Examining Medicare Proposals to Improve Patient Access to Care & Minimize Red Tape for Doctors” focused on enhancing patient access within the Medicare program, with a particular focus on physician reimbursement. During two sessions, the committee heard from a panel of distinguished witnesses, including:

  • Dr. Meena Seshamini, Director of the Center for Medicare at the Centers for Medicare and Medicaid Services
  • Leslie Gordon, Director of Health Care at the U.S. Government Accountability Office
  • Paul Masi, Executive Director of the Medicare Payment Advisory Commission
  • Dr. Steven Furr, President-elect of the American Academy of Family Physicians
  • Dr. Debra Patt, Executive Vice President from Texas Oncology
  • Mr. Joe Albanese from Paragon Health Institute
  • Mr. Matthew Fiedler, Joseph A. Pechman Senior Fellow at the Brookings Schaeffer Initiative on Health Policy at the Brookings Institution.

These witnesses provided insights into their experiences with Medicare, drawing from their roles as physicians and health policy experts. Committee members engaged in discussions about the potential impact of modifying physician reimbursement payment models, particularly the physician fee schedule, on addressing physician shortages and enhancing healthcare access for senior citizens and rural communities.

In the opening remarks of the hearing, Chairman Guthrie (R-KY) highlighted the goals, which include improving senior citizens’ access to care, reducing administrative burdens for providers, and updating physician reimbursement models to ensure high-quality care while maintaining Medicare’s solvency. He stressed the unsustainable trajectory of healthcare spending and the need to sustain and strengthen Medicare for older adults. Vice Chair Bucshon (R-IN) emphasized his personal investment as a healthcare provider and the importance of supporting providers in prioritizing patient care over paperwork. Ranking Member Eshoo (D-CA) shared concerns about Medicare reimbursement negatively impacting physician recruitment and retention, advocating for bipartisan solutions and the removal of administrative burdens like the Merit-Based Incentive Payment System (MIPS) and prior authorization. Rep. Rodgers (R-WA) pointed to rising inflation and its impact on Medicare, calling for reducing red tape and the importance of sustaining access to care. Rep. Pallone (D-NJ) expressed frustration with the political process and urged Republicans to cooperate, emphasizing the need for a sustainable Medicare system and bipartisan solutions while criticizing Republican-led bills without clear funding sources and the rejection of HR.5630.

Overall, Democrats expressed concern that most of the discussion drafts they were expected to review were introduced less than a week before the hearing, with many of these drafts being incomplete. Meanwhile, Republicans contend that increasing inflation has contributed to higher costs for medical practices.

 

Group of Senators Launch Bipartisan Senate Mental Health Caucus

U.S. Senators Alex Padilla (D-CA), Thom Tillis (R-NC), Tina Smith (D-MN), and Joni Ernst (R-IA) have announced the formation of the bipartisan Senate Mental Health Caucus, with additional members including U.S. Senators Cory Booker (D-NJ), Shelley Moore Capito (R-WV), Susan Collins (R-ME), John Fetterman (D-PA), Amy Klobuchar (D-MN.), and Lisa Murkowski (R-AK). This caucus aims to address the national mental health crisis by providing a platform for Senators to collaborate on bipartisan legislation, raise awareness of mental health issues, and reduce the stigma surrounding mental health. The caucus will focus on improving prevention and early intervention, expanding the mental health workforce, enhancing crisis response services, and increasing access to evidence-based mental health treatment and solutions for all Americans. In recent years, Congress has made bipartisan efforts to advance mental health services, including the establishment of the 988 Suicide & Crisis Lifeline and investments in community-based mental health services, which the Senate Mental Health Caucus seeks to build upon and ensure their effectiveness.

Administrative Action

The Centers for Medicare and Medicaid Services (CMS) recently announced that they will expand coverage to include Amyloid Positron Emission Topography (PET) scans, which are important tools to determine which patients are viable candidates for new Alzheimer’s drugs. Specifically, CMS is removing its national coverage determination at §220.6.20, ending coverage with evidence development for PET amyloid imaging. Additionally, CMS will remove the current limit of one PET scan per lifetime. Novel anti-amyloid treatments, such as lecanemab now demand a confirmed diagnosis of mild cognitive impairment or mild Alzheimer’s disease backed by evidence of amyloid-ß presence in the brain. To align with CMS’ national coverage determination (NCD), Medicare will provide coverage for lecanemab when medical professionals and clinical teams engage in real-world evidence gathering through a registry. As per the proposed modification, patients under original Medicare will be subject to a standard 20% coinsurance on the Medicare-approved cost of lecanemab, applicable after meeting their Part B deductible.

Research

recent survey by the American Cancer Society Cancer Action Network (ACS CAN) reveals that the drug shortage crisis in the United States continues to impact cancer patients and survivors, with 10% reporting negative effects on their care. Most of these individuals struggled to find substitute medications (68%) and experienced treatment delays (59%). The survey underscores the urgent need for Congress to address the drug shortage issue promptly and comprehensively to prevent future crises.  Additionally, the survey found that biomarker testing, an important tool in cancer care, significantly influenced treatment decisions. 77% of those who had undergone biomarker testing reported that it provided valuable information for better treatment, and an equal percentage of those who had not been tested expressed interest in having it if they were suitable candidates. Equitable access to biomarker testing is crucial for ensuring that more individuals can receive effective treatment for their specific cancer, with thirteen states having already enacted legislation to expand access to biomarker testing.


Registration Open for 2023 Annual Conference

The Public Sector HealthCare Roundtable 2023 Annual Conference Moves to Washington, DC

The conference features a new location, a revised format, and a great agenda!

Wednesday, Nov. 1 to Friday, Nov. 3, 2023

The Roundtable’s highly-regarded annual conference provides members and guests a unique opportunity to hear presentations by high level government officials and key experts – from Congress and the Administration, academics, benefit consultants, plan administrators, advocates and industry leaders in an intimate dialogue-oriented setting.

After years of successful conferences in Old Town Alexandria, we have outgrown our space at the Alexandrian Hotel. This year we will hold our conference at the historic Mayflower Hotel in Washington, DC. The new location will undoubtedly improve the overall experience for all of our attendees.

In recent years, many of our attendees have urged us to schedule more free time in the conference agenda for networking. Since we understand the importance of this networking time, we have revised this year’s agenda to incorporate longer breaks and more time before evening receptions.

This year, the conference will begin at Noon on Wednesday, November 1st and will conclude at Noon on Friday, November 3rd. By adding time on Wednesday, we have been able to add critical content, lengthen our breaks, and add free time prior to any evening activities.

Although we certainly believe the best way to experience our conference is in-person, this year’s conference will once again feature a virtual option. Any health plan that registers at least one individual to join us in Washington, will be eligible to register online attendees.

Register Today