This week, the House Ways and Means Subcommittee on Health chaired by Rep. Peter Roskam (R-IL) held a hearing on “The Current Status of and Quality in the Medicare Advantage Program.”

This hearing was a chance for lawmakers to discuss with stakeholders how the government can get out of the way to help spur competition and better outcomes, examine quality measurement, and learn about the consumer experience within the program.

As Chairman Roskam said at the start of the hearing:

“As the Medicare Advantage program grows in size, we must ensure it is able to grow with technological advances and evolving healthcare delivery techniques. The Medicare Advantage program has come a long way and can be used as a testing ground for many healthcare innovations that are unavailable in traditional Medicare. How we incentivize innovation that leads to better care quality, access, and health outcomes is vital.”

Throughout the hearing, Subcommittee Members heard from health policy experts and advocates about the current status of the Medicare Advantage Program.

Karoline Mortensen, Ph.D., Associate Professor at the University of Miami, addressed health care quality metrics:

“The majority of health care quality measures used for public reporting are process measures. They can be informative to consumers about the care they can expect to receive. A limitation to process measures is that they may assess whether the provider prescribed a medication therapy, but not whether the patient filled the prescription, correctly took their medication, or if their outcomes improved due to the therapy.”

Addressing Andrew Toy, Chief Technology Officer at Clover Health, Rep. Sam Johnson (R-TX) asked:

“Mr. Toy, you mentioned that Clover health is having problems contracting with certain health systems and provider groups in some areas because of lack of local competition. I understand this is driven by consolidation within the health provider industry. Can you tell me if this is something you’re seeing more frequently, and how it is impacting the health and the cost and delivery of care?” 

Mr. Toy responded:

“This is definitely something we are seeing … what we see is that when we go to see provider groups – especially if they are consolidated or if they have a lot of market share in a particular area – they have leverage which enables them to ask very high prices … this means that we have to either agree and make things very expensive for the folks on the plan in that area or we have to basically not agree and then we don’t have network sufficiency per CMS rules. This is a very difficult situation to be in.”

Rep. Lynn Jenkins (R-KS) asked “how can current star ratings measures change to focus on and incentivize better health outcomes?”

Mr. Toy answered:

“When we look at star ratings, often times they are not directly connected to the outcomes … they are a proxy towards them … one thing we can do from our perspective is to really analyze the data.”

Daphne Klausner, Senior Vice President at Indepedence Blue Cross, addressed issues with health care metrics:

“There are a number of star rating measures that the plan can’t control, like overall rating of the health plan … You don’t know what could have happened to that patient that day. Maybe they waited in their doctor’s office for two hours, very likely, and all of a sudden they have a bad rating of the health plans, even though this is something we can’t control.”

Rep. Erik Paulsen (R-MN) commented:

“There is a pretty strong recognition that Medicare Advantage is improving people’s heath based on testimony we’re hearing from you .… It’s using best practices and care delivery, it’s the robust data analytics, it’s proven value-based care and the care management models that are available through MA … Whatever we can do to help encourage more enrollment in a program that could lead to better health outcomes for our seniors and lowering health care costs is the direction we need to go.”

Rep. Paulsen went on to ask:​

“Do you think CMS could increase enrollment in the MA program by conducting another [marketing] campaign?”

Daphne Klausner, Senior Vice President at Independence Blue Cross, responded:

“I think CMS could focus in areas where MA penetration is lower than in other areas. For instance, in Philadelphia we have 40 percent, but there are some areas that have 10 percent penetration of MA. It would be great if CMS and MA could work together to figure out why it’s lower in certain pockets.”

Chairman Roskam asked how often metrics for Medicare Advantage change. Ms. Mortensen responded:

“In Medicare Advantage, the goal posts are always moving, and the plans don’t know the goal posts ahead of time, and they are told maybe midway through what is going to be looked at and what is a 3-star, a 4-star, a 5-star. So, none of these guys going in know what is going to be measured and what the cutoff is going to be.”

Chairman Roskam closed the hearing by thanking the witnesses. Click here to learn more about this hearing.