Medicare Compliance & Reimbursement

Health plans will need to act fast to take advantage of Medicare Advantage

Many questions surround the future of the revamped Medicare Advantage, but that hasn't dampened health plans' enthusiasm for the program.

America's Health Insurance Plans' annual Medicare conference last week attracted more than double the registration of 2003's record-high attendance, AHIP President Karen Ignagni said at the conference's Oct. 19 opening session.

In the keynote address, Centers for Medicare and Medicaid Services Administrator Mark McClellan laid out his broad vision of a future in which insurers and providers are rewarded for providing evidence-based, coordinated care that tailors treatments to individuals' health needs and manages chronic conditions before they become serious problems.

McClellan also suggested some specific directions in which he'll seek to move. Praising fledgling pay-for-performance programs in Medicare and elsewhere, he suggested that the agency hopes to pilot P4P reimbursement in several sectors, likely including health plans, for which he noted that consensus quality measures have existed for years.

Another priority: coordinating individual beneficiaries' care. Many health plans already coordinate care, and a large chronic-care improvement pilot is being launched for fee-for-service Medicare, said McClellan.
But care coordination can spread even farther, he vowed: Over time, "Medigap plans can also be a source of additional support for managing chronic diseases."

Current MA timelines are as follows: Regions will be announced soon. The answer to one of the insurance industry's most burning questions - where and how big will be the areas to be served by new regional preferred provider organizations and prescription drug plans - will be revealed "well ahead of the end of this year," said McClellan.

State-sized regions for larger states and multistate regions encompassing some smaller states appears a likely scenario, at least for the opening years of the program.

It's important to allow established care-delivery networks to continue operating, said McClellan. Some such networks do cross state boundaries. CMS has "seen some considerable expression of interest in multistate regions," he said.

At the same time, it's important that regions not be so large that plans have trouble scaling up to meet the quick deadlines, McClellan said. E-prescribing standards are on track for earlier-than-required delivery. The MMA doesn't require implementation of electronic-prescribing standards until 2008, but federal agencies are working now on proposed standards and will announce them "soon," said McClellan, who added that he wants Medicare e-prescribing "in place by 2006."

Linking all Medicare patients and their providers through electronic health records is a top priority for McClellan. To guide coverage decisions, the administrator wants to quickly develop evidence on the effectiveness of care regimens for various populations, and that depends on real-time production of clinical information on a broad scale.

As for establishing registries to produce data on pharmaceutical treatments once Medicare's [...]