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AHIP urges more flexibility in new value-based Medicare Advantage model

Industry watchdog is calling on CMS to allow insurers even more flexibility and to expand the pilot program to all states.

Susan Morse, Associate Editor

CMS headquarters-MarylandCMS headquarters-Maryland

While America's Health Insurance Plans said it supports the new Medicare Advantage value-based insurance design model, the industry watchdog is calling on CMS to allow insurers even more flexibility and to expand the pilot program to all states.

In April, Mark Hamelburg, senior vice president, Federal Programs for AHIP, wrote a letter to Hoangmai Pham, acting director, policy and programs group, for CMS's Innovation Center, urging the agency to expand the medical conditions to be tested.

The model is currently testing seven clinical conditions or combinations of these conditions: diabetes, chronic obstructive pulmonary disease, congestive heart failure, patients with a past stroke, hypertension, coronary artery disease and mood disorders.

In 2018, CMS will add rheumatoid arthritis and dementia to the clinical categories.

"Allowing plan flexibility would enable the evaluation of a broad range of VBID interventions that are improving the management of chronic conditions for health plan enrollees in the commercial market," Hamelburg said in the letter. "These programs are rapidly evolving as new evidence-based clinical guidelines and research become available and it is crucial MA plans are permitted to incorporate these developments in their VBID programs." 

[Also: AHIP tests 'one stop' provider directory model as fines threaten insurer inaccuracies]

Originally, AHIP had concerns that insurers would be unable to promote their value-based design plans to consumers who are shopping around for Medicare plans during open enrollment, which begins Oct. 15.

The nine insurers participating in the new model are only able to tell members of the design benefits after they've signed up for a Medicare Advantage plan.

"CMS seems to be concerned about giving (this information), knowing that they are limiting this only in certain places, states and diseases," Hamelburg said. "There was some concern there could confusion. … We did not support this restriction, but to be fair to CMS we understand their perspective on this. As an industry we really do believe that accurate information is critical to ensure beneficiaries know the choices they have available. The goal is to know before they enroll."

AHIP also recommended that CMS extend plan's cost sharing capabilities to Part D drugs.

"We believe that allowing reductions or elimination of cost-sharing for prescription drugs is critically important, especially for VBID interventions that target enrollees suffering from chronic conditions and facing significant prescription costs," Hamelburg said.

[Also: Out-of-network providers charge on average 300 percent more than Medicare rate, AHIP says]

Since CMS has already expanded the model for 2018, AHIP expects CMS would continue to consider expanding flexibility to Medicare Advantage plans, especially as those plans continue to grow in numbers and in popularity.

The insurers in the model for 2017 include Blue Cross Blue Shield, Fallon Community Health Plan, Tufts Associated Health Plan, Geisinger Health Plan, Aetna, Independence Blue Cross, Highmark, UPMC Health Plan and the Indiana University Health Plan.

The current MA-VBID model limits plan participation from seven states; Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. In 2018, CMS will add Alabama and Michigan as test states.

"It's been the industry's position for a very long time now, this is something that is really important, from a policy perspective," said Hamelburg. "There's been a recognition of the need to move towards value-based purchasing and value-based care."

[Also: AHIP responds to Hillary Clinton's attack on insurance consolidation]

The Centers for Medicare and Medicaid Services Innovation Center model aligns incentives not only between providers and payers, but also with the patient, Hamelburg said.

The aim of the model is to test whether giving members initiatives to use high-value services, such as offering a zero copay on eye exams to diabetic patients, really does result in an increase in the quality of care while reducing costs.

"We've been advocating for the demonstration nationwide," said Liza Assatourians, vice president for Federal Programs for AHIP. "We've been pushing for that for several years now."

"The reason insurers are so interested, this is the wave of the future... We want to make it big and make it broad," said David Merritt, executive vice president for Public Affairs and Strategic Initiatives for AHIP.

Twitter: @SusanJMorse

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