Molly Turco [00:00:02]:

We’re really at this tipping point right now that happened last year, which was that now Medicare Advantage represents over half of all Medicare enrollees. And in some areas it’s much, much higher. And as we’ll get to in rural areas, increasingly the penetration is going higher as well. So it’s a really important inflection point. MA is now 2% of the US GDP. So as you said, this is a crucial topic, and I think it’s a great time be having the conversation we’re having today.

Narrator [00:00:36]:

Welcome to Hospitals in Focus. From the Federation of American Hospitals, here’s your host, Chip Conn.

Chip Kahn [00:00:45]:

With headlines in Washington focused on Congress’s budget reconciliation bill, debates over Medicaid and enhanced tax credits. One critical piece of the coverage puzzle that has slipped off the front page is Medicare Advantage, but it remains the largest story in health care. In this episode of Hospitals in Focus, we turn our attention to the rise of Medicare Advantage, or ma, plans that are reshaping Medicare. With enrollment now surpassing half of all Medicare beneficiaries, questions about MA’s sustainability, transparency, and impact on caregivers and patients are more pressing than ever. To unpack what the transformation of Medicare by MA means for patients, providers, and the broader healthcare system, I’m joined today by Molly Turco, a former CMS official and current health policy consultant at her firm, MTT Strategies. Molly’s unique perspective from inside and outside government helps us understand how, how we got here, what’s working, what’s not, and where MA may be headed next. Thanks for joining us today, Molly.

Molly Turco [00:01:59]:

Thanks for having me, Chip.

Chip Kahn [00:02:01]:

Molly, to get started, let’s look at Medicare Advantage, where it is sort of its growth trajectory and what that means across the country.

Molly Turco [00:02:10]:

Absolutely. So as you alluded to, Chip, we’re really at this tipping point right now that happened last year, which was that now Medicare Advantage represents over half of all Medicare enrollees, and in some areas it’s much, much higher. And as we’ll get to in rural areas, increasingly the penetration is going higher as well. So it’s a really important inflection point. MA is now 2% of the US GDP. So as you said, this is a crucial topic, and I think it’s a great time to be having the conversation we’re having today.

Chip Kahn [00:02:45]:

So you’re helping me get this out. Let’s take a deeper dive. What is happening in rural America and what’s happening in urban centers where MA is really reaching a new point?

Molly Turco [00:02:59]:

Absolutely. You know, in 2010, roughly, MA was about 25% penetration. So that was the affordable Care act made some changes to MA payment and the intent was to really address payment issues. But at that time, fee for service, traditional Medicare was clearly the dominant player, especially in rural areas where you saw very little Medicare Advantage penetration, meaning MA enrollment. And that had a lot of factors as, you know, for a managed care plan. It was difficult to build a network in rural areas. So that has changed. Now we are over 50%.

Molly Turco [00:03:42]:

So it has gone from, you know, a few million to now it’s about 35 million enrollees in Medicare Advantage. And that has really impacted all of Medicare and not just Medicare. I would argue all of the US Healthcare system, some of the biggest systems and healthcare companies, really the core of their business is Medicare Advantage. And so vertical integration, you know, you know, acquisition of providers, really the Medicare Advantage part of the healthcare system is driving a lot of changes. And I think it’s really important to understand the impact that Medicare Advantage is having. One thing that you alluded to that we saw a lot when I was working at center for Medicare at CMS was this new increased enrollment in rural areas and rural hospitals that had always kind of dealt with Medicare Advantage and had some struggles with it, but it wasn’t enough of their book of business for it to be something that was a central focus. I feel like that has really changed, and I know you can speak to that, but we heard a lot from hospitals that were really struggling, navigating contracting with MA plans or navigating utilization management, payment delays, things like that. So I think that that has really brought some of these issues into the forefront and gotten a broader stakeholder group of different types of politicians or others who traditionally had been very pro Medicare Advantage.

Molly Turco [00:05:19]:

I think there are concerns now when you’re hearing growth from MA plans, but also from providers in your district. I think it’s kind of a healthy tension that now we can really talk these issues through and see what’s best for the enrollees.

Chip Kahn [00:05:34]:

Traditional Medicare is a fee for service program beneficiaries. Medicare beneficiaries qualify to go to the hospital, to go to doctors. They can go to any doctor that takes Medicare. Almost all hospitals obviously take Medicare and other kinds of providers. What’s the difference? Just to sort of lay a base here for our discussion and our audience, what’s the difference for a beneficiary between belonging to a plan, an MA plan, and the traditional kind of coverage that I just described?

Molly Turco [00:06:07]:

So, as you just described, you know, if you’re a traditional, so you default into Medicare, you don’t actively enroll in a plan, so essentially the government is your insurer. So you go and see any provider, you don’t have a network and you, your provider then bills the government. You have set cost sharing. You usually enroll in a Medigap plan, also called a Medicare supplement plan. So that helps with some of your cost sharing. But generally you’re not super focused on, as I said, your network. And you would also have to go out and separately buy a standalone part D prescription drug plan. So you would have to buy.

Molly Turco [00:06:45]:

Those are all private choices. You’d have to go and enroll in those to get prescription drug coverage. But that’s traditional Medicare. In Medicare Advantage you would go onto the plan finder or work with an agent and a broker and you most normally people enroll in a plan that’s both MA and part D. So you get your MA and your prescription drug coverage, which means all of your A and B. So hospital and provider services and prescription drug are through that plan. And you know the, the pros that you hear a lot from beneficiaries is the way that the payment system is set up is that plans are able to provide if they bid for less than the government says they will pay. You can keep some of those dollars in what are called supplemental benefits.

Molly Turco [00:07:28]:

So you can add dental vision cost sharing, which a enrollees like. On the con side, you, you have a network so you can’t see anyone. You know, if you get a diagnosis and want to go to the top cancer center, wherever they’re not in your network, that can be a real problem. And prior authorization and utilization management techniques are techniques that MA use and can be legitimate tools to steer you towards high value care. But I think increasingly there are concerns that it is used inappropriately to not allow enrollees to access their part A and part B benefits that they are entitled to as Medicare enrollees. So that’s really the trade off. And that trade off can be very difficult. We heard time and time again how difficult it is to enroll and to weigh those things.

Molly Turco [00:08:20]:

And when you don’t have things like accurate provider network data, so you don’t know which docs are in your network or not when you don’t have statistics on. Okay, does this plan use prior authorization more than this plan? What do they. I know that I have COPD and I’m a diabetic, so I know the drugs I’m on. How can I look to make sure that they, you know, they don’t prior off stuff. I know I’m in need. It’s very difficult to see that it’s Very easy to see the good things. So the supplemental benefits, the, you know, cash card. So I think that the tension there is, you want to make sure that people know the pros and cons of both traditional Medicare and Medicare Advantage.

Molly Turco [00:09:02]:

But it can sometimes be difficult. That being said, I think that a lot of beneficiaries really like their Medicare Advantage and I think what we heard a lot was a lot of people like their Medicare Advantage and a small portion really, really have concerns with it and sometimes can feel trapped because they aren’t able to go and get a supplemental benefit. Because once you are in, in some states you can’t go back out and get your supplemental benefits because you’ll be underwritten if you have pre existing conditions. So there’s a lot of tricky trade offs that enrollees need to weigh which I think can be very difficult for them.

Chip Kahn [00:09:39]:

You know, and even for the Medicare population, few people are sick at any given time or fewer people, I should say are sick at any given time. And I want to get back to that in a minute to talk about this issue of what patients and their caregivers have to face when they do have this coverage and become ill. But before we get to that, we’ve talked about it from the beneficiary side. Could you give us a description of how this works from the plan side and why are the plans in this in the first place? And we have some plans that are HMOs and we have other plans that are more traditional. PPO or other kind of health carrier, health insurance carrier. How does this work for them? Because obviously all of them need to make a margin out of this sustainable.

Molly Turco [00:10:31]:

Absolutely. And I think, you know, I, when I was a grad student, I was drawn to Medicare Advantage because you know, fee for service. Medicare can be very difficult to create a value based system. So you know, having downside risk and CMS and others are doing great work there. But what’s nice about Medicare Advantage is really the chassis of this. It’s called capitated. So you get a global payment. You know, the government decides, okay, based on that person’s risk mix or what have you, the diagnoses they have, their demographics.

Molly Turco [00:11:03]:

Here is a set amount of money, manage them within that money and if you’re able to do a better job managing their diagnoses, then you get to keep a portion of that. So really the premise is a great premise to incentivize the right things. If it’s regulated well, you know, and, and what Medicare Advantage plans have been able to do when they have been successful, and many have been very successful is kind of the devil’s in the details of your payment amount that you get for each of your enrollees, as I said, is based on diagnoses, and plans have gotten very, very good at those diagnoses. So there’s been a lot of reporting and, you know, the Wall Street Journal and others of how good these plans have gotten. And really, that’s the rub is that the government is trying to really predict what people will cost based on those diagnoses, and plans are legitimately trying to diagnose those codes to maximize their payment to then provide care. And I think the concern has been, is that the government hasn’t necessarily gotten that right. I think many would argue so those payments are arguably higher than they need to be, which has allowed plans to have very healthy margins and also allowed them, as I alluded to earlier, supplemental benefits. So kind of the delta between what they bid and what the government pays them is pretty big.

Molly Turco [00:12:35]:

And it was always intended to be an incentive for plans to manage care and prevent, you know, unwarranted hospitalizations, keep people healthy at the end of the day. And I think that the balance there, there is a lot of concern, bipartisan concern, that, you know, over the next 10 years, we’re going to spend about $9.2 trillion on Medicare Advantage plans, and 1.3 trillion of that will be on these supplemental benefits. So when have we moved from a, hey, let’s create an efficiency to oh, my goodness, we are pumping a lot of money in there, and there’s been a lot of margin that is in there as well. And so I think that has been the concern that you. There was concern many years ago before there were changes in the Medicare Modernization act, that there was underpayment to Medicare Advantage plans. So there really weren’t a lot of MA plans. And there was a desire during the Bush administration to grow ma I think some would argue it was supercharged in a way that now we’ve paid them too much and we’ve seen this crazy growth. So I think that the key is how do we balance those things where it’s been a little bit of a feast and famine in the Medicare Advantage space.

Chip Kahn [00:13:55]:

Well, I hate to say it, but I’ve been around long enough working on Capitol Hill, working for the insurance industry, working now many, many years for hospitals to remember when plans by Medicare were paid 95% of an average amount with the idea that they should be saving money. Then eventually, when I was working on The Hill in 97, we invented Medicare plus Choice, which was to build the plans, but we didn’t pay enough. And then obviously, as you described during the bush administration, in 2003, we had the Medicare Modernization act that started us on a new trajectory. And so plans are clearly well paid, but they have to provide extra benefits. But at the same time, there is a lot of dissonance on the other end when you’ve signed up on one end and you enjoy the benefits and the extra coverage. But on the other end, if you get sick, then you meet what some consider to be sort of this competition between value and just utilization control, and you hit prior authorization, you hit plans, trying to, frankly, from the provider perspective, maybe even underpay. Let’s talk a bit about prior authorization and observation care and all these denials. What is that all about, both from the patient standpoint and the provider standpoint, as far as you can tell?

Molly Turco [00:15:23]:

I think having worked with MA plans for many years, I think what MA plans would say is when utilization management is done right, it’s really about addressing inappropriate utilization and which ultimately reduces premiums and is better for the enrollee, can prevent fraud. It can. You know, right now, there’s a concern with skin substitution. You’re seeing a lot of that in fee for service Medicare. You’re not seeing that in ma. And an MA plan would argue that’s because we are not. We don’t see a lot of clinical value there. So we’re saying no to that.

Molly Turco [00:15:59]:

That’s an example of when prior authorization and utilization management can be a positive. So I think it’s an important tool that can be used when. When used appropriately and appropriately means we’re going to make sure that this meets all the criteria of Medicare. Because the core thing here is MA plans have always had to provide all of the part A and B benefits, as I said, that you’re entitled to. It’s not allowed to say, you know what, we don’t think there’s clinical value in that. Even though that is what you are entitled to. Plans can’t do that. They can just decide, okay, do you meet the criteria for xyz and then do that.

Molly Turco [00:16:35]:

So I think what has happened, what I would argue is that we got a little bit off track here. And I think of prior authorization in two buckets. It’s the. Are people getting the care they’re entitled to and need, are medically necessary, and is the payment happening in a timely manner? And sometimes people get the care they need, but then the provider is not getting paid in a Timely manner. So that first bucket, what happened is CMS said, okay, you have to follow fee for service. But fee for service isn’t a perfect recipe, as you know. It’s paid in a different way. You have these local Medicare max, the contractors who they pay.

Molly Turco [00:17:19]:

And so there’s a lot of decisions that are made. So there aren’t clear rules of the road on every, in this specific situation, that person is entitled to X or Y. There are things called local coverage determinations, national coverage determinations. Those are big things. So in this situation, you, you are entitled to service or what have you. So what CMS has said for many years is you’re allowed to fill in those blanks and have clinical criteria where fee for service isn’t clear. However, there weren’t clear rules of the road of how you could fill those blanks in. So the Biden administration, after many years of OIG reports and other reports, basically has gone through the steps of trying to fill in some of those blanks.

Molly Turco [00:18:02]:

So saying okay, this, it has to be from clinical evidence, it has to be widely accepted so you can fill in those blanks. But it can’t be willy nilly. It has to be rooted in these clinical standards. It has to be transparent. So those are the main things that have gone on in addition to process things which we can get into. So it’s kind of the clear rules of the road of what it means to ensure that these individuals get all of their A and B benefits and medical necessity. What does that mean? How do we define that? And then separately it’s okay, how fast do we do it? What is the situations where it has to be a quicker turnaround because it’s an emergency. So that’s kind of the bucket of getting the enrollee access.

Molly Turco [00:18:49]:

The other bucket is kind of the payment. So the bene’s held harmless, they’ve gotten the service, let’s say they’re admitted. And then after the fact, the plan is saying, okay. Actually we think that that was not a legitimate admission. We’re not going to pay. I think that as we alluded to earlier, again where this tension is happening, the most I would argue is in these rural areas where hospitals are came to us at CMS to say, you know, as I said, they used to have hardly any ma. And now I was looking at an interesting Kaiser Family foundation report saying that now in very rural areas it’s roughly 42% enrollment in MA and in like semi rural areas it’s up to 50%. So it’s almost up to the national average of MA enrollment and the amount of inpatient stays of hospitals that are in those rural areas have doubled.

Molly Turco [00:19:45]:

So it’s becoming really a lot of tension on those rules. And happy to dig in on the payment, but I’ll stop there.

Chip Kahn [00:19:53]:

I think we should go a little bit further into that because the, there’s a difference in some ways on average between the rural hospitals and the more urban, which is the rural hospitals tend to have a higher proportion of Medicare and Medicaid patients on average than urban hospitals have. They just don’t have as many commercial patients. So with the numbers you’re describing, the impact of Medicare and Medicare patients, whether they’re planned patients or traditional patients on the rural hospital is actually more significant than in a lot of urban areas. So this is really a big deal for them. And the sustainability of access to hospital care.

Molly Turco [00:20:34]:

Absolutely. And I think the reason that rural hospitals come up again and again is I think they, they’re less likely to be part of a bigger system in our experience. So it takes a lot of FTEs, a lot of energy appeals to fight back. And what we’re hearing is these smaller entities that aren’t part of a big system that has a whole kind of appeal area that they’re not able to. And I think your point is well taken on the people who are duly eligible for Medicaid and Medicare, because back to my earlier point of the profitability of ma. So a lot of information has found because a lot of people who are duly eligible have a lot of complex needs, they tend to be able to be coded aggressively, for lack of a better term, with lots of diagnoses. And MA plans have found that those can be some of the most profitable enrollees. So plans very aggressively try to enroll dually eligible individuals.

Molly Turco [00:21:35]:

So I think that has driven some of this penetration in rural areas because of the profitability of those individuals for plans. So that has led to the point you’re talking about, which is having these complex, duly eligible individuals who are very high cost individuals, individuals that the hospital and the plan are taking care of. And where is that tension between those two entities? And I think there was recently an article about the amount of provider systems and hospitals that are leaving networks in the middle of the year. And we saw that a lot. And you’re entitled to a special enrollment period in certain chances where you can move plans if it’s enough of a change to the system. But that has hugely increased over the past few years. So I think that that tension is happening. And you’re an enrollee halfway through the year and the hospital you go to is no longer in network.

Molly Turco [00:22:34]:

That, that’s a really stressful situation, especially if the next hospital is, you know, technically meets the network adequacy standard. So it’s within the geographic area, but it’s not the one you go to. I think that we’re seeing a lot of disruption because of these disputes between hospitals and plans.

Chip Kahn [00:22:56]:

So from a policy standpoint, you talked about CMS beginning to change. I mean historically CMS took a very hands off position when it regarding providers versus plans because the law in a sense that provides for the payment and other rules for the plans in a sense is sort of laissez faire and, and sort of says the plans will have contract contractual arrangements with providers. And that’s really outside Medicare, Medicare’s purview. But there has been, you know, more attention both by CMS and with Congress talking about prior authorization bills and, and other kinds of changes that potentially could be made in terms of changing these relationships inside of the plans versus providers and the beneficiaries that depend on those providers. What’s the trend here? Where do you see all this going both in terms of CMS itself and legislatively? Obviously we have a new administration and we’re into. But these issues are still around and at the end of the day, CMS’s role is to serve the Medicare beneficiaries and assure them that they’re going to get their care whichever coverage they have.

Molly Turco [00:24:13]:

Absolutely. You know, I think what you’re referring to is the non interference clause which very clearly states that CMS is not getting involved with how the plan is contracting with its providers. The point of the MA program is, you know, the government is going to pay that MA plan and then the plan, you know, within certain rules can contract. And so I think what, from my view, the best thing for both CMS and Congress to do is back to those rules, rules of the road. So put on those parameters that make sure that there isn’t any funny business that’s making it impossible for the spirit of different things to happen. I think one example is the Trump administration. The Biden administration proposed something related to reopenings which meant if someone was admitted to the hospital and the plan said okay, that’s fine and paid the hospital, they couldn’t then later reopen it under the guise of an audit, kind of a loophole and say, you know, that it didn’t turn out the way the doctor thought it would. We’re going to reduce your next payment by X amount because we shouldn’t have paid that.

Molly Turco [00:25:20]:

So by changing that and finalizing it and closing that loophole previously someone would say hey, put that in your contract that you can’t do that. And I think you hear from plan, from providers, it’s really difficult to put that in the contract, especially if you’re smaller provider system and a large health plan. So that was example of that loophole shouldn’t exist. CMS can just close it. And I think, you know, payment delays are another example you’re hearing about or other things like that where in theory it should be in a negotiation but it’s increasingly difficult to put those in. So I think that’s where Congress and CMS within its authority should focus is okay, we’re not going to set the exact payment rules, but if there are tactics that are leading to beneficiary harm or preventing appropriate payment and or unclear rules of the road. We heard a lot from small plans actually who said we feel like the spirit of the rules is clear but there’s technically some wiggle room and we find that our lawyers say we don’t want you to risk, risk it where you know, we’ll, you will lose in a dispute with a provider. Whereas the claim from the small plans would be that they felt like their competitors, larger plans are less risk adverse and so they’re, they’re doing things that, that allow them a competitive advantage in terms of bidding and, and everything that then attracts enrollees away.

Molly Turco [00:26:54]:

So I would argue that it shouldn’t be seen as overregulation or things like that. It’s, it’s part of a competitive market to have those rules clear so that within plan competition happens and that it’s a fair contract dispute between providers and plan. So I think that’s important. And in terms of the Trump administration, I do think, and my hope is that prior authorization especially is an area with a lot of bipartisan consensus. A lot of what we did in terms of simplifying the prior authorization process, a lot of that came from the timely access bill, which was a bipartisan bill that you know, providers put together. I think plans were largely supportive of. So my hope would be this is an area that has bipartisan support and is viewed as something that just needs to be there and is clear. And so there wouldn’t be rolling back of changes.

Molly Turco [00:27:49]:

If anything, there’s building on it just to make sure that everyone’s on the same page in terms of how this is supposed to work.

Chip Kahn [00:27:56]:

You know, one of the other bones of contention I think from the Plan side In terms of CMS’s concerns, you know, has been around this issue of risk. The premiums to sort of simplify it obviously are adjusted somewhat for patients or members of the plans, potential patients who may be considered because of conditions they have of higher risk. And how that’s calculated by the plans, how the plans determine that affects the rates they receive. And there’s some contention as to whether or not, I guess that from the CMS side that’s led to some rates being higher than they should be in terms of what CMS is paying. Where do you think that’s issue’s going? And the plans consider it a cut. I think if some of this has been reduced by cms, CMS considers it appropriate management of the plans. Where is this going and is this going to affect sustainability of plan coverage?

Molly Turco [00:29:01]:

I think the. Is MA paid accurately? Is the central question in ma and there is back and forth debates on this all the time and I think it’s very difficult to get that right. But I, I do think that there is. Now it seems to me we are hitting a tipping point where it seems like there’s bipartisan concern that there needs to be more steps to be taken to make sure payment is accurate. I will say though, and we navigated this when I was at cms, you have to strike that balance of there’s certain, you know, large plans who are really good at diagnosis capture and smaller plans that aren’t as good. So you may want to address payment accuracy, but you have to be very careful that you don’t do it in a way that incentivizes plans that don’t want to code aggressively to have to do that to keep up, you know. And I think that there is a healthy conversation to be had by some plans who treat very complex patients that feel like the overpayment debate can sometimes be overblown and that there is very legitimate need for getting that high payment right. What you don’t want, and you used to have in the days before a more complex MA risk adjustment system was people cherry picking because they didn’t want the sickest individuals.

Molly Turco [00:30:27]:

We almost ironically have the opposite now where people want the sickest individual. So again with all this MA policy, it’s the balance we don’t want to over incentivize enrolling high risk, high need people because you can code them really well. And again, I think another concern that a lot of people have is are there entities that are coding really well and steering via prior auth but not truly managing care, not truly making better outcomes. A lot of times plans will point to reduced hospitalizations, and you hear from providers or physicians being like, wait, do we know that that was an avoided hospitalization because that individual was inappropriately downgraded to an observation stay or because their COPD was managed? And I think that’s a hard question to tease out, but we really need to know what is happening there because it is becoming the dominant player. And we really, you know, I think sometimes the debate can be simplified to, ma is overpaid, end of story. But it definitely is more complicated than that. And I think that that conversation is starting to happen now in a more nuanced way. It used to be okay if you don’t, if you’re not updating MA by a huge amount, and if supplemental benefits aren’t going up, you hate ma, you’re trying to kill it.

Molly Turco [00:31:48]:

And I would hope we’ve moved to a time now where there, you can say, you know, there are certain people, I think a lot of Republicans fall into this bucket, certainly the Trump administration of we really like ma. We arguably like it better than Medicare Advantage, but we don’t want to overpay and we want to make sure that the payment is accurate. We don’t feel like supplemental benefits need to be going up and up and up. There comes a, you know, a point of diminishing returns. And how do you do that? I will Last comment. I will say that makes MA really, really difficult. Is unlike something like drug pricing, where it’s very clear you reduce drug prices. It’s good for the beneficiary.

Molly Turco [00:32:26]:

Reducing MA payment reduces supplemental benefits to beneficiaries. So it’s always tricky to articulate why addressing overpayment is good for a beneficiary. So that will remain the trickiest part. You can talk about fraud, waste and abuse and things like that, but it ends up being a really difficult thing to address. MA payment.

Chip Kahn [00:32:47]:

Yeah. You know, the difficulty for hospitals and we have to have hospital access is that and we’re there to take care of the patients whether they need a long hospitalization or short hospitalization. The problem is when they start, when the plans, you know, play games, frankly, with what’s an observation visit versus an inpatient visit. And someone sits on the floor in a hospital inpatient for five or seven days. And they say, well, that should have been observation. And they pay observation and they underpay hospitals. That can go for a while. But at some point in the rural areas or even in urban areas where you’ve got 70 or 80% of your patients or plan patients.

Chip Kahn [00:33:32]:

It’s unsustainable, and that’s sort of the issue. And you don’t see plans buying hospitals because they’re complicated and hard to run and expensive. You see plans, in a sense buying practices and physicians because that’s where they can control the care and hopefully enhance the value of the care. What’s the trajectory of all this? I mean, do you see it continuing? I mean, are we gonna be at 70 or 80% of Medicare beneficiaries covered by plans? Does, does, does that seem to be the near future?

Molly Turco [00:34:09]:

I think it’s a great question. I think an interesting point is you do have parts of the country that are saturated. You know, the Miami Dade, places like that, that they’re already at 75, 80, 80%. And there comes a point where there are certain people who never will want to go into Medicare Advantage. You often see a lot of wealthier individuals who want to stay in traditional Medicare, for example. So there are parts of the country that are saturated. That being said, I think every estimate I’ve seen is that in the next 10 years it will go up to 60%, 75%. So I don’t think there’s any indication that MA enrollment will slow down.

Molly Turco [00:34:48]:

I think increasingly with vertical integration, there are increasingly hospital systems that are also MA plans. I think to your point, it’s which ties more, tends to be more of the academic medical centers and things like that. So I think all of that will continue to happen and we’ll see where what tension that puts on the policy. So a lot of MA payment is built on fee for service underlying data. When you’re in a county that’s 80% MA and only 20% fee for service data, it doesn’t really work because that’s not a representative sample. So there’s a lot of tough questions. Just as this system where fee for service, traditional Medicare was the dominant player, now that MA is the player. Okay.

Molly Turco [00:35:39]:

Which is the one that you base the payment on. So I think those will be interesting questions. And you know, I think to your point about this hospital plan, and in terms of the tension between hospitals and plans, I hope that the conversation becomes more nuanced. I think for a while it’s been a lot of finger pointing or, you know, value based arrangements aren’t advanced because they’re not ready or we’re not willing. And I think I’m seeing more hopefully of having more nuanced conversations about, okay, prior authorization, what exactly is happening and how can we have really specific solutions to that because I think we do need these surgical solutions to these big issues where for a while there just hasn’t been a lot of new ideas in how to do that. And so I would hope that now MA is the biggest player in Medicare that there can be more of those really technical conversations to allow some common sense policies to happen.

Chip Kahn [00:36:40]:

Well, Molly, this has just been great and I really appreciate you giving us this 30,000 foot view and then drilling down and then going over the basic issues that face Medicare beneficiaries and those trying to provide care to them and obviously the plans that are providing coverage for so many. As I said, this is the biggest thing in Medicare right now. It probably is the future of Medicare and we really appreciate your expertise and your contribution to trying to make the system better.

Molly Turco [00:37:15]:

Thanks Chip. It was a pleasure.

Chip Kahn [00:37:16]:

As MA becomes the predominant choice for seniors, how do we solve these issues we’ve discussed without sacrificing the ability of hospitals and other caregivers to provide the access to care that patients need? It’s clear from my conversation with Molly that the issue of Medicare Advantage, how it works, the balance between the plans, the providers and the beneficiaries is still a work in progress. A lot needs to be done and it’s job one for all of us, including the policymakers, to find a way that Medicare Advantage can be sustainable on the one hand, but also not be a disruption, but be a part of a seamless continuum of health for those that depend on Medicare.

Narrator [00:38:16]:

Thanks for listening to Hospitals in Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the federation on social media @FAHHospitals and follow Chip @ChipKahn. Please rate, review and subscribe to Hospitals in Focus. Join us next time for more in depth conversations with healthcare leaders.

Molly T. Turco is a Medicare policy expert with over 15 years of experience shaping national healthcare strategy. Molly has dedicated her career to helping healthcare work better for people. She recently launched MTT Strategies, where she provides strategic and policy consulting services with a focus on Medicare Advantage and Medicare Part D. She previously served as Senior Policy Advisor for Medicare Advantage and Part D at the Center for Medicare at the Centers for Medicare & Medicaid Services (CMS), where she helped lead major initiatives to improve transparency, payment accuracy, and consumer protections in Medicare Advantage and Part D — including reforms under the Inflation Reduction Act. Prior to her work at CMS, Molly led Medicare policy efforts at the Blue Cross Blue Shield Association and the Better Medicare Alliance. She also brings experience as an investor consultant and public health researcher. Molly holds a BA from Middlebury College and a Master of Public Health from the Dartmouth Institute for Health Policy & Clinical Practice. She lives in Washington, D.C., with frequent trips to her home state of Vermont.