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Medicare Payment Coalition for Frail Beneficiaries

The Medicare Payment Coalition was sponsored by the NCCC and continues to be active. For information regarding participation in the MPC, contact Valerie Wilbur at vswilbur@frontiernet.net

The purpose of the MPCFB is to develop a collective strategy for refining payment methods for specialized M+C plans for frail, chronically ill Medicare enrollees to accurately reflect their costs.

Related Articles:

Risk Adjustment for Health Plans Disproportionately Enrolling Frail Medicare Beneficiaries
Gerald F. Filey, M.S.P.H.

Medicare+Choice: Doubling or Disappearing
Robert A. Berenson, Health Affairs Web Exclusive

Geography and the Debate Over Medicare Reform
John E. Wennberg, Elliott S. Fisher, and Jonathon S. Skinner

Medicare+Choice 2003: An Analysis of Managed Care Plan Withdrawals and Trends in Benefits and Premiums
Lori Achman and Marsha Gold, Mathematica Policy Research, Inc.
Research supported by The Commonwealth Fund.

Members:
Community Health Partnership—Eau Claire, WI
Elder Care of Dane County—Madison, WI
Elder Health—Baltimore, MD
Elderplan—New York, NY
EverCare—Minneapolis, MN (national market)
Fairview Partners—Minneapolis, MN
Geriatrix—San Diego, CA (national market)
Inglis Innovative Services—Philadelphia, PA
SCAN—Long Beach, CA

Problem: Managed care, in principle, provides significant advantages for providing the right care, at the right time, in the right place, for people with serious and disabling chronic conditions. Unfortunately, current M+C payment methods contain incentives for M+C plans to avoid high-cost patients. Many M+C plans that have maintained a "managed care" orientation are increasingly at financial risk, as their plan beneficiaries age and their improved benefits and performance methods attract more high-risk populations. Most "specialty M+C plans", (e.g. plans serving people dually eligible for Medicare and Medicaid, Social HMOs, and Evercare) have special payment provisions. But the future of these plans is also in jeopardy without an adequate risk adjuster to the Selected Significant Disease (61- condition) model, currently established by CMS as the foundation for future M+C payments. CMS is aware of this issue, but risk adjustment is still an emerging science, and national data sets cannot be manipulated to fully account for cost differences in serving a high-risk population. Most M+C plans serve a disproportionate number of healthy people, and advocacy efforts by AAHP and others could thwart the application of methods that would ensure a more equitable payment for high-risk populations.

Solution: Conduct policy research and advocate for CMS to establish risk adjustment methods to the 61-condition model to ensure fair and equitable payment for Medicare beneficiaries who are frail and have multiple medical conditions.

 


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