January 25, 2018
Submitted electronically via email to CompetitionRFI@hhs.gov
Re: Promoting Healthcare Choice and Competition Across the United States
To Whom It May Concern:
California Health Advocates appreciates the opportunity to comment on the Request for Information Promoting Healthcare Choice and Competition Across the United States (the RFI).
California Health Advocates (CHA), a non-profit organization founded in 1997, is the leading Medicare advocacy and educational voice for more than 5.6 million California Medicare beneficiaries.
We would like to begin by expressing our disappointment with the way The Department of Health and Human Services (HHS) chose to release this Request for Information (RFI). In particular, we are concerned the decision to label it “informal”—and therefore forego publication in the Federal Register—could limit public awareness of the RFI, skew the responses, and suppress important feedback from critical stakeholders. We strongly urge all federal agencies to be maximally transparent regarding opportunities for public comment, in order to gather the best possible information.
This RFI presents a broad set of questions regarding the promotion of health care choice and competition, including how existing regulations and policies may stymie these goals. The RFI states that in part, HHS is requesting this information in furtherance of the administration’s efforts to “encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.”
We agree with the goal of letting people with Medicare make free, open, informed choices about the care they receive, and to have their choices prioritized and respected. We note that for a market to be “free” it must ensure that clear, complete information is available to consumers. This RFI notes that “improv[ing] access to and the quality of information that Americans need to make informed healthcare decisions, including data about healthcare prices and outcomes” is a necessary component of any attempt to improve choice and competition. We agree that people with Medicare must be given all the information, tools, assistance, guidance, and protection from bad actors they need in order to make the best choices for their particular, unique, circumstances.
What State or Federal laws, regulations, or policies (including Medicare, Medicaid, and other sources of payment) reduce or restrict competition and choice in healthcare markets?
Medicare can be confusing or even overwhelming, especially when a person has chronic illness, limited resources, or a lack of help. Choosing among traditional Medicare, Medicare Advantage (MA), Medicare Part D, and supplemental or “Medigap” options can make it almost paralyzingly complex. We rely on people with Medicare to make informed, savvy choices—in other words, to “vote with their feet”—so that competition can reward plan innovations that work, identify bad actors and problematic behaviors, and reduce both beneficiary and program costs. Yet, studies show that older adults struggle to compare plans1 and often do not change MA or Part D plans even when doing so may lead to lower premiums and reduced cost-sharing.2 To put it simply—people with Medicare are overwhelmed with information, but it may not be the information they need.
As policymakers consider putting beneficiaries on the hook for plan and health care choices, the absence of quality, useful information becomes increasingly punitive. We cannot support proposals that will shift costs to people with Medicare, penalize them for failing to make optimum choices, or otherwise transfer burdens onto their shoulders. Doing so becomes especially egregious when people are kept in the dark about what their choices are or what they might mean. The existing resources are insufficient. They must be improved before new complexities are added.
Currently the only Medicare choice tool is Plan Finder. While Plan Finder allows head- to-head comparisons of prescription drug plans, its utility is limited as it does not even allow a beneficiary to search across plans for particular providers. And there is no adequately-resourced tool to fill the gaps. The vital State Health Insurance Assistance (SHIP) program, which offers one-on-one personalized assistance,3 is woefully underfunded, faces challenges meeting current demands, and is constantly under threat.4 1-800- MEDICARE, while a needed resource, is no substitute for in-person assistance. We urge the administration not to move forward with any proposals to increase plan flexibility that would also further complicate beneficiary choice until adequate tools and resources are available for beneficiaries to effectively evaluate and compare their options.
We also note that as plan offerings become more complex, the administration’s responsibility to oversee plans appears to be getting less emphasis. Such oversight is an obligation that the Centers for Medicare & Medicaid Services (CMS) owes to beneficiaries, and is only increased by increasing complexity.
We might point out that CMS’s inability to negotiate prices for prescription drugs further compounds beneficiaries’ options, as plans are free to choose the pharmaceutical benefit managers that give them the “best price for a restricted formulary” regardless of how it will impact the beneficiary.
Recently an 81 year old beneficiary with diminished capabilities succumbed to marketing mailers from a United Healthcare plan endorsed by AARP and enrolled in a Medicare Advantage HMO plan without understanding the implications of her decision. She just “trusted AARP!” The local HICAP (California’s SHIP) will attempt to unravel her situation to ensure that she and her daughter understand the consequences of her decision, and make any needed changes based on her unique circumstances.
What State or Federal laws, regulations, or policies (including Medicare, Medicaid, and other sources of payment) may promote or encourage anticompetitive behavior in healthcare markets?
CMS must advance policies that encourage people with Medicare to make active and informed choices about the coverage option(s) that are right for them, selecting among traditional Medicare, Medicare Advantage plans (including integrated Medicare- Medicaid options), supplemental Medigap policies, and stand-alone Part D prescription drug plans. A free and competitive market should serve the wants and needs of the consumer, not place a thumb on the scale that would push people with Medicare toward specific options. In addition, these issues work against people with Medicare making high-quality choices that reflect their actual needs and desires:
- Cumbersome and opaque appeals processes;
- Lack of sufficient oversight;
- Star ratings that do not reflect plan quality; and
- Proposals to increase complexity.
Mass marketing, both mail and media, during Open Enrollment or for those who are new to Medicare further complicates and confuses beneficiaries, as they only see material from companies that are engaging in this type of outreach. So other companies or options are not made known to beneficiaries. And if they are not aware that there is help available through SHIPs, they potentially make uninformed decisions based on who markets the most and is most visible in the media.
What State or Federal grants or other funding mechanisms (including Medicare, Medicaid, and other sources of payment) reduce or restrict competition and choice in healthcare markets?
Recent emphasis on MA, in addition to rules that privilege MA availability over that of Medigap, create an uneven playing field between choices about how to access Medicare benefits. We are troubled by what appears to be deliberate downplaying, or even failure to mention, the availability of traditional Medicare in some CMS publications. This interferes with traditional Medicare and Medigap’s ability to compete fairly. The ability to choose traditional Medicare, with or without a supplemental Medigap plan, must be preserved and promoted equally with MA.
As an example, there are many rural counties in California that have no Medicare Advantage plans available to Medicare beneficiaries. Consequently, they are not aware that they have the option to purchase Medicare Supplemental plans. Even if Medicare Advantage (MA) plans were available, their particular circumstance may preclude the option of choosing a Medicare health plan, e.g. their doctor is not in their network, or they may be served by a Native American health clinic that does not accept patients with an MA plan.
What State or Federal grants or other funding mechanisms (including Medicare, Medicaid, and other sources of payment) may promote or encourage anticompetitive behavior in healthcare markets?
Medicare should always pay a fair price for quality service. We believe it is in the best interest of both taxpayers and people with Medicare to fairly and efficiently reimburse for care provided by MA plans. Indeed, the purpose of offering MA options is to achieve better quality and lower costs through competition and innovation.
Changes to MA payment rates must be transparent, predictable, and gradual to allow health plans to find operational and other efficiencies, so rate cuts do not become benefit cuts or premium hikes. MA plans can provide real value, but must not come at the expense of people with Medicare accessing their Medicare benefits affordably. Bearing these principles in mind, we continue to encourage HHS and CMS to more assertively address inappropriately inflated MA payments resulting from “upcoding” practices.
In California, Medicare beneficiaries have choices depending on their geographic location. If they reside in urban or densely populated suburban communities, they may have reasonable options for Medicare health plans. However, these plans are as good as their networks and prescription drug benefit formularies. Beneficiaries do not make plan enrollment decisions based on competition, they base their decision based on access to their providers and cost. The plans’ cost of doing business is a moot point if they cannot afford their co-pays or find that their doctors are not in their network or have a restricted formulary.
The inability for CMS to negotiate prices is a significant factor in plan options. In particular, Part D plans often have limited or restrictive formularies that CMS approves, and gives beneficiaries the difficult choice of paying bills or getting their needed medications. Take the case of Mrs. T who lives in a rural northern California county. She was recently widowed and with that came a reduction in her income. As a diabetic who required expensive medication and insulin each month, she was faced with paying basic bills or getting the medication she needed. She enters the donut hole in the second month of the year. She came to the HICAP (SHIP) office for help evaluating her health insurance. She was willing to go without some medical coverage if it meant having more money for prescriptions.
During the appointment Mrs. T was screened for Extra Help (LIS), a benefit rarely mentioned by plans. Her income was too high and she couldn’t apply for that. The HICAP counselor asked if she had been on Medicare due to a disability prior to age 65 – Mrs. T confirmed that she had been. This opened an opportunity for her to apply for the 250% California Working Disabled Program. The program was explained in detail to Mrs. T and she stated she had been to the Medi-cal office asking for any assistance that could be provided and was told that she didn’t qualify for any programs, her income was too high. The HICAP counselor provided Mrs. T with the information on how to apply. Mrs. T left the appointment with a better understanding on how to save money on her Supplemental Plan, Part D, and a valuable program that was available to her.
That is why the SHIPs play such an important role in assisting beneficiaries make informed choices using clear and complete information if it was available on Medicare.gov. Neither Medicare health plans, supplementary nor prescription plans offer the type of assistance that SHIPs offer.
What suggestions do you have for policies or other solutions (including those pertaining to Medicare, Medicaid, and other sources of payment) to promote the development and operation of a more competitive healthcare system that provides high quality care at affordable prices for the American people?
In addition to the proposals above, people with Medicare would benefit from changes within the program that would increase their agency to make informed choices, get the care they want and need, and hold plans accountable for problems.
We suggest that CMS:
- Explore streamlining Part D appeals, which is an essential safety valve in the program;
- Improve model development at the CMS Innovation Center to better protect consumers; and
- Create an Alternative Payment Model Ombudsman to monitor the beneficiary experience.
A more comprehensive data source of plan information should be available on Medicare.gov. Beneficiaries should not rely solely on marketing material or what plan representatives or agents disclose.
We welcome the opportunity to increase choice and competition in Medicare by ensuring people with Medicare have the information, tools, assistance, guidance, and protection from bad actors they need to make the best choices for their particular, unique circumstances. Currently, people with Medicare are more paralyzed than empowered due to the lack of usable information, tools, and one-on-one assistance. If we move to multiply the number of plans, we are only limiting further the ability of Americans to make informed health care decisions. Creating a new, infinitely customizable array of plans shifts the burden onto Medicare recipients.
We must ensure that people with Medicare are provided the help they need now, before any added complexity makes this a more difficult lift. Only then can we genuinely say that the market promotes real competition and real choice.
At every step, our goal must be to ensure better health, better coverage, and better care.
Thank you for the opportunity to submit comments. If any questions arise concerning this submission, please contact me at 916-231-5110.
1 Gretchen Jacobson, Christina Swoope, Michael Perry & Mary C. Slosar, “How are Seniors Choosing and Changing Health Insurance Plans?” Kaiser Family Foundation (May 13, 2014), http://kff.org/medicare/report/how-are-seniors-choosing-and- changing-health-insurance-plans/.
2 Kaiser Family Foundation, “Few People Switch Medicare Advantage Plans Each Year, Raising Questions About Whether Seniors Have the Tools and Information They Need To Compare Plans” (September 20, 2016), http://kff.org/medicare/press- release/few-people-switch-medicare-advantage-plans-each-year-raising-questions-about-whether-seniors-have-the-tools-and- information-they-need-to-compare-plans/; Jack Hoadley, Elizabeth Hargrave, Laura Summer, Juliette Cubanski, and Tricia Neuman, “To Switch or Not to Switch: Are Medicare Beneficiaries Switching Drug Plans To Save Money?” Kaiser Family Foundation (October 10, 2013), http://kff.org/medicare/issue-brief/to-switch-or-not-to-switch-are-medicare-beneficiaries- switching-drug-plans-to-save-money/.
3 National Council on Aging (NCOA), “Issue Brief: FY18 Medicare SHIP Funding” (July 2017), https://www.ncoa.org/resources/ncoa-issue-brief-fy18-medicare-ship-funding/.
4 Mindy Yochelson, “Medicare Advocates Don’t Want SHIPs to Sail Away” Bloomberg Health Care Blog (May 24, 2017), https://www.bna.com/medicare-advocates-dont-b73014451475/.