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
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.
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.
Community Health PartnershipEau Claire, WI
Elder Care of Dane CountyMadison, WI
Elder HealthBaltimore, MD
ElderplanNew York, NY
EverCareMinneapolis, MN (national market)
Fairview PartnersMinneapolis, MN
GeriatrixSan Diego, CA (national market)
Inglis Innovative ServicesPhiladelphia, PA
SCANLong 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.