Medicare & Medicaid

6 ways to improve Medicare Advantage physician networks

Andis Robeznieks , Senior News Writer

Enrollment in Medicare Advantage (MA) plans has grown 285% since 2004, but numerous factors threaten the stability of the program. The AMA has presented Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma with a set of recommendations to improve patient communication while stabilizing physician networks and ensuring network adequacy.

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More than one-third of Medicare beneficiaries—about 20 million people—were enrolled in a Medicare Advantage plan last year, and that share is expected to steadily grow to 42% by 2028. Yet beneficiaries must navigate an environment that is growing unstable because of shrinking networks, unpredictable severing of relationships with trusted physicians, and the false appearance of choice.

Some beneficiaries in large metropolitan areas have 40 different MA plans to choose from, and the average senior has 21 choices on their MA menu. But these numbers are deceptive because most of these plans are operated by a UnitedHealthcare, Humana or a Blue Cross Blue Shield affiliate.

Also, more than one in three enrollees is in a narrow network, with fewer than 30% of physicians in a county participating in the plan, according to Kaiser Family Foundation research cited in an AMA Board of Trustees report.

As plans shrink their networks, physicians are subject to “no-cause terminations” and patients have no way of knowing whether the doctor they know and trust will be in the same network next year, the report says.

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This bad situation is made worse because patients’ chief resource for comparing Medicare Advantage plans—the Medicare Plan Finder (MPF)—is difficult to use, gives incomplete information and lacks prominent instructions, according to a U.S. Government Accountability Office report cited in the AMA’s letter to CMS. Additionally, network-provided directories contain “significant errors.”

“The AMA recommends that CMS adopt a suite of policy proposals to enhance network directory accuracy, network adequacy, network stability, and communication with patients about MA plans’ physician networks,” James L. Madara, MD, the AMA’s executive vice president and CEO, wrote in the letter.

The AMA has outlined these specific recommendations for CMS.

Ensure MA network directory accuracy. CMS found significant errors in nearly half of the directories it reviewed, including physicians not practicing at the listed location, incorrect phone numbers and physicians who were not taking new patients when the directories said they were.

CMS should:

  • Require plans to submit accurate directories every year before open enrollment and whenever there is a significant change to a network physician’s status.
  • Publicly report accuracy scores on MPF.
  • Take enforcement action against plans that either fail to maintain accurate directories or have an insufficient number of in-network physician practices open and accepting new patients.

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Ensure network adequacy standards provide adequate access and support coordinated care. CMS needs to publish the research supporting the adequacy of the ratios and distance requirements it uses to determine network adequacy. The AMA also recommends CMS conduct a study of the extent to which networks maintain or disrupt teams of physicians and hospitals that work together.

Ensure lists of contracted physicians are more easily accessible. Beneficiaries trying to use the MPF to select a plan may need to call individual plans to determine whether physicians are in a plan’s network. The lack of physician network information on the MPF significantly limits its utility.

The AMA recommends that CMS simplify the process for beneficiaries to compare network size and accessibility by expanding the information for each MA plan on the MPF website to include:

  • The number of contracted physicians in each specialty and county.
  • The extent to which a plan’s network exceeds minimum standards in each specialty, subspecialty and county.
  • The percentage of the physicians in each specialty and county participating in Medicare who are included in the plan’s network.

Develop an effective communication plan. Medicare patients report frustration and difficulty comparing plans and avoid switching plans due to the difficulty in accessing their preferred physicians. The letter cites research by the National Council on Aging that found poorly presented information and outdated, misleading user design led to patient confusion and poor plan selection.

Measure network stability. Patients need to know if they have to keep changing doctors. “No-cause terminations” are difficult for physicians to challenge and can occur before patients complete a treatment plan or find an in-network physician who can take over their care. Dr. Madara called for banning such terminations during physicians’ initial or renewal terms of their MA plan-participation contracts.

Process improvements for recurring physician input regarding MA network policies. The AMA urges CMS to start a network adequacy task force that would review and develop policies to address network adequacy to ensure the agency keeps getting input from physicians and patients.