AAFP Seeks to Improve Medicare Advantage, Part D Programs

March 22, 2017 09:36 am News Staff

The AAFP recently offer detailed comments and recommendations to HHS officials regarding the agency's advance notice(www.cms.gov) of proposed payment and policy changes to Medicare Advantage and prescription drug plans for 2018.

In a March 3 letter(5 page PDF) signed by AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., the AAFP responded to specific CMS proposals related to three issues: quality measures, Medicare Part D formulary submissions and network adequacy determinations.

Quality Measures

In the Feb. 1 advance notice, also referred to as a "call letter," CMS discusses quality measures for 2018, including those that are new or changing and those that should be removed.

The AAFP's response was brief and to the point: CMS must work to harmonize quality and performance measures. The AAFP urged CMS to use core measure sets developed by the Core Quality Measures Collaborative, a multistakeholder group that includes the AAFP.

Doing so would "ensure parsimony, alignment, harmonization and the avoidance of competing quality measures among all payers," said the AAFP.

Story Highlights
  • The AAFP recently responded to CMS' proposed payment and policy changes to Medicare Advantage plans and prescription drug plans in 2018.
  • The primary issues covered in the Academy's comment letter are quality measures, Part D formulary submissions and network adequacy determinations.
  • The Academy also took advantage of the opportunity to reiterate previous recommendations to CMS on how to improve the Medicare Advantage program.

The letter pointed out that physicians, and particularly family physicians, "bear the brunt" of quality and performance measurement due in part to a maze of performance measures included in various quality improvement programs.

Formulary Submissions for Medicare Part D

CMS notes that the 2018 formulary submission window opens on May 15 and closes on June 5; plans must meet the June 5 deadline to ensure their formulary's review.

CMS also proposes to implement safeguards in Part D plans related to patient safety and opioid prescriptions -- including putting systems in place to block patients' attempts to seek multiple opioid prescriptions from various physicians.

In response, the AAFP urged CMS and other affected parties to consult the Academy's policy on patient-centered formularies before implementing any such new policies.

Regarding CMS efforts to address opioid abuse, the AAFP cautioned against decreasing access to opioids for patients who need powerful pain relievers. "Our main concern is the use of the CDC guideline(www.cdc.gov) to set limits," because the guideline lacks a strong evidence base for a number of its recommendations, said the AAFP.

"Furthermore, prescribing guidelines are made to assist clinicians in making clinical decisions and must not create rules that restrict clinical decisions or penalize clinicians," said the AAFP.

Network Adequacy Determinations

CMS calls for the submission of provider network information specific to each Medicare and Medicaid plan by Sept. 19 to ensure that these networks are sufficient to meet patient needs.

The AAFP urged CMS to place more responsibility on Medicare Advantage Organizations (MAOs) for ensuring that their networks are adequate and that provider directories are current.

"If CMS moves forward with creating a nationwide Medicare Advantage provider database, the AAFP would like to reiterate its position that physicians play a key part, but MAOs should provide the bulk of the information," said the AAFP.

"Network information should be aggregated directly from the MAOs' accurate and up-to-date provider directories. Physicians should not be expected to go to another website to update the nationwide provider database."

In the same letter, the AAFP took advantage of yet another opportunity to reiterate previous recommendations to CMS about changes the agency should implement to make Medicare Advantage a better program for physicians and their patients.

For example, among other things, the Academy urged CMS to find a way to

  • improve the Medicare annual wellness visit by ensuring that the visit, which includes advance care planning, is provided by a patient's primary care physician rather than outside commercial entities that continue to subvert this patient benefit;
  • maintain adequate physician networks within health insurance plans, with a specific caution against any proposal that would unilaterally remove a physician without cause or appeal;
  • streamline its claims review process, which currently subjects physicians to multiple HHS contractors and overlapping audits that result in an enormous unfunded administrative burden on physicians;
  • address beneficiary cost-sharing for primary care services; and
  • reduce prior authorization hassles.

Related AAFP News Coverage
Letter to CMS
Guard Against Narrow Networks in Medicare Advantage Plans, Says AAFP