Medicare Advantage plans could be on track to reach over $75B in overpayments this year – nearly 3x prior estimates – causing researchers at the USC Schaeffer Center for Health Policy and Economics to issue a pressing call for policy reform.
The USC study found that traditional fee-for-service Medicare beneficiaries with lower-than-average expenditures are significantly more likely to switch to Medicare Advantage plans. Favorable selection at its finest.
- For context, CMS sets MA rates based on the county-level expenditures of those in traditional FFS Medicare, and they’re intended for beneficiaries with average expenditures – not systematically below average.
- As a result, risk-adjusted expenditures for the 16.9M new MA beneficiaries who made the switch from traditional Medicare between 2006 and 2019 were substantially below average, causing large overpayments due to the favorable selection effect.
This pattern of favorable selection more than doubles the $27B (6%) overpayment estimate from MedPAC for 2023, which primarily reflected “coding intensity” ($23B) and Star Rating (quality) bonuses, but didn’t include an adjustment for selection bias.
- The researchers estimate that favorable selection alone could cause overpayments to the tune of 14.4%, which would surpass $75B when combined with MedPAC’s estimate of other factors.
The authors propose two potential strategies for improving the accuracy of MA rates:
- Reform the current approach of linking MA rates to average expenditures of traditional Medicare beneficiaries by including measures to reduce the impact of aggressive coding and mandating new data reporting requirements to improve comparability.
- Abandon the current approach and institute competitive bidding by MA plans to let market forces determine rates with the aim of capturing efficiency gains for taxpayers instead of increasing revenue for MA plans.
Medicare Advantage enrollment has been skyrocketing over the past decade, and over half of all eligible beneficiaries are now enrolled in a private plan. As traditional Medicare enrollment continues to decline, basing MA rates on FFS expenditures will only grow increasingly problematic, and this study does a great job underscoring the need for some serious reform.
Population health management extends far beyond the moments of care delivery, which is why Lightbeam Health Solutions is acquiring Jvion to move from “predictive to prescriptive” intelligence, while bringing new health equity offerings to millions of patients.
Lightbeam helps payors and providers manage risk by generating patient cohorts for over 42M lives to provide proactive insights that ensure care is delivered when it can have the largest impact on a patient’s trajectory.
- Jvion incorporates clinical, socioeconomic, and behavioral data to identify hidden patient risk factors across various diseases, then recommends appropriate clinical interventions taking into account these SDOH influences.
- The acquisition will integrate Jvion’s AI-enabled prescriptive analytics and social determinants of health solutions with Lightbeam’s existing population health management services, allowing Lightbeam to incorporate more risk factors into its patient cohorts.
Jvion’s SDOH solutions are well-aligned with Lightbeam’s other offerings, building an impactful health equity component into the “Deviceless RPM” services added through last year’s acquisition of CareSignal.
- CareSignal’s Deviceless RPM service uses a combination of automated text messages and IVR calls to gather self-reported patient data, enabling value-based organizations to sustainably scale care teams without sacrificing engagement.
- With Jvion and CareSignal both integrated into its portfolio, Lightbeam now provides a complimentary suite of services that optimizes risk profiles, suggests interventions based on SDoH factors, and continuously monitors patient progress.
Integrating Jvion’s prescriptive analytics into Lightbeam’s core population health offering improves the cohort creation at the center of the service while allowing more SDoH data to feed into its insights. The combination of these health equity enhancements and CareSignal’s remote patient monitoring capabilities position Lightbeam as a highly scalable solution for end-to-end population health management, which seems like a solid value proposition at a time when labor shortages are the single biggest concern for most providers.
Healthcare data analytics startup Truveta announced the launch of its deidentified clinical data platform designed to provide insights on rare medical conditions and COVID-19.
Truveta was formed earlier this year by 14 health systems with a mission of “saving lives with data.” The announcement revealed that it has raised $195m to develop its platform and expand its partner base.
- The “Truveta Platform” promises real-time answers to public health questions by aggregating partners’ deidentified patient data and communicating it in an interactive dashboard. Data inputs include all EHR data, physician notes, images, and genomics, which can then be studied based on demographics, comorbidities, and vaccine manufacturers.
- The addition of three new health system members (Ochsner Health, Saint Luke’s, UnityPoint) pushes Truveta’s total partner count to 20, representing over 16% of US patient care from clinical sites in 42 states.
- Preliminary insights shared in the press release found that Moderna recipients experience the most adverse events and J&J recipients have the most hospitalizations. Truveta also found that people with high-risk conditions like cancer or HIV are no more likely than the general population to have a breakthrough case, which the authors believe could be a result of risk averse behaviors.
Truveta is aiming to expand its member base as quickly as possible, taking the “moral imperative” route by calling for new health systems to join its platform to improve care during the pandemic.
Although Truveta states that its data is “licensed for ethical medical research, not to target advertising to patients or physicians,” the company isn’t registered as a charity, creating tension between its mission and the path to revenue.
That said, the Truveta Platform has the potential to have a positive impact on public health by making fresh insights available from existing data, and the new funding provides significant resources to find the balance between successful health and business outcomes.
Sometimes having a great community impact is as simple as a corporate mega-buyout. Health-tech company WellSky is acquiring Healthify for an undisclosed amount to expand access to its healthcare networks while addressing the social determinants of health (SDOH).
- What’s SDOH? All of the socio-economic conditions that affect health outcomes or quality-of-life, including: access to healthcare, education, economic stability, and community.
- What’s Healthify? Healthify connects healthcare providers with community-based organizations, then allows them to track the success of interventions with an interoperable technology platform.
- Why does WellSky want it? Instead of building its SDOH offerings from the ground up, WellSky can leverage Healthify’s network of community organizations (and its closed-loop referral platform) to help payers and providers effectively coordinate care.
Adding Healthify’s community-based SDOH referral platform to WellSky’s existing technology suite creates one of the largest social services networks in the US. The scale of the combined solution should allow for better ROI analysis and clinical data, which might mean improved patient outcomes and health equity over the long run.