Beneficiaries Moving from Traditional Medicare Fueled MA Expansion
A comprehensive analysis recently featured in Health Affairs delves deeply into the intricate trends and patterns of beneficiaries switching between traditional fee-for-service Medicare and Medicare Advantage (MA). The study, driven by researchers at the Department of Health and Human Services (HHS), offers revealing insights into the considerable shift of beneficiaries migrating from traditional Medicare to MA. Between the years 2006 and 2022, there was a more than threefold increase in the switch to MA. Conversely, the transfer from MA back to traditional Medicare witnessed a decline, with these switch rates becoming notably more pronounced post-2019.
The research methodology was anchored on data sourced from the Centers for Medicare & Medicaid Services (CMS) Medicare Enrollment Database in conjunction with the Medicare Risk Adjustment Processing System. All under carefully monitored data use agreements with CMS. The researchers methodically extracted demographic, regional, and enrollment data for every beneficiary within the Medicare Enrollment Database. Their analytical approach identified beneficiaries who had newly joined MA within each year. This pool was further divided, categorizing beneficiaries as those who had recently become eligible for Medicare and those who were already eligible. A key component of the study was to pinpoint the “switchers”, individuals transitioning between traditional Medicare and MA.
Key Highlights of the Findings Include:
A noteworthy rise in the proportion of switchers among the newly enrolled in MA was observed. In 2011, this figure stood at 61%, but by 2022 it had surged to 80%.
Certain demographics displayed pronounced switching trends. Black beneficiaries, those eligible for both Medicaid and Medicare (dual-eligible), and disabled beneficiaries exhibited a heightened propensity to switch, encompassing both directions.
Age and health conditions played pivotal roles. Beneficiaries who were younger and in better health conditions demonstrated a stronger inclination to transition from traditional Medicare to MA. However, they had reduced tendencies to move from MA to traditional fee-for-service Medicare.
Significantly, two-thirds of all annual switches between MA and traditional Medicare in the year 2022 transpired in January. This surge can be attributed to the open enrollment period.
The research findings allude to a pattern. It appears that younger, healthier beneficiaries demonstrate a preference for MA, while the older, less healthy beneficiaries lean towards transitioning away from MA and opting for traditional Medicare. Those who revert to traditional Medicare can access a more expansive spectrum of healthcare providers. Moreover, they potentially sidestep prior authorization procedures and the looming possibility of care denials, recently spotlighted by the HHS Office of Inspector General. Beneficiaries with more severe health conditions might be drawn to traditional Medicare due to the flexibility it offers in terms of care access, compared to the financial risk-mitigation framework of MA.
Surging Medicare Advantage enrollments are straining medical groups dedicated to its members. This challenges these groups, especially in maintaining staffing levels for quality care. One critical need is for Certified Risk Coders (CRCs) who ensure compliant HCC risk adjustment coding in line with the Medicare risk adjustment model. To counteract this, many top-tier medical groups are turning to AI-driven tools like ForeSee Medical risk adjustment software. With advanced healthcare natural language processing, ForeSee has observed a significant speed increase during chart reviews. This efficiency means fewer coders are needed for the rising number of Medicare Advantage members, and doctors can enjoy more direct interaction with patients. For medical groups serving Medicare Advantage members, software like ForeSee Medical is increasingly seen as essential to handle the enrollment surge in these plans.
Blog by: The ForeSee Medical Team