CMS plans in MA: show us your algorithms

All technical inquiries from the agency’s new Medicare Advantage (MA) Request for Information (RFI).

To paraphrase the well-known children’s book2022 has been a terrible, horrible, not good, very bad year for MA.

Not in terms of registration growth and carrier profits, mind you. But the PR has been dismal— noting that the MA plans are too much paidthat prior authorization (PA) requirements contribute to the burnout of nursing staffand, according to a OIG reportthat medically necessary services that fall under AP coverage rules are often delayed or denied.

Now CMS has issued an RFI asking MA plans how they can make the program more equitable, accessible, innovative, affordable and collaborative.

The use of data for improving the MA plan and program is interspersed throughout the RFI. Specific and detailed requests relate to what the plans can do – and what the CMS can do – to better exploit the data for better results.

Data sought for each objective

  • The best data to advance equity. CMS seeks better data related to race, ethnicity and language; sexual and gender identity; people with disabilities and language/communication difficulties; cultural identity and religious preferences; socio-economic need; and people in rural and underserved communities.
  • A focus on socio-economic data. CMS adds specific questions, including MA plan challenges for “obtaining, leveraging, or sharing this data.”
  • Use and results of additional benefits. To improve both, CMS asks what “standardized data elements” it could collect and how they would also help DOH, equity and cost sharing.
  • Applications for usage management (UM). With a Senate Bill Aiming to improve home-directed PA, CMS wants to know which of its data, if any, helps UM/AP enforcement and how MA plan data could align for better efficiency.
  • Value based contracts. Data for evaluating VBC models as part of the MA program.
  • Dynamics of competition. CMS is looking for data on vertical integration and its impact on the MA market.

Multiple questions on data exchange and interoperability

For its pillar “Stimulating innovation to promote people-centred care”, CMS specifically asks:

  • What are the key technical and other decisions made by MI plans and providers regarding data sharing agreements to inform population health management and care coordination efforts?
  • How could the CMS better support the efforts of AM plans and providers to appropriately and effectively collect, transmit and use appropriate data?
  • What approaches could CMS pursue to advance health information interoperability between MA plans and other stakeholders?
  • What are the opportunities for the recently released version Framework for exchange of trust and common agreement to support improved health information exchange for use cases relevant to MAID plans and providers?

CMS seeks algorithmic intelligence

Health algorithms – understanding and regulating them – are a growing priority for CMS. In its MA RFI, the agency seeks detailed information about the MA plan algorithms, including:

  • The algorithms used to identify members in need
  • Algorithm prediction targets, such as cost and usage
  • Algorithm testing and biases related to differential outcomes and how plans mitigate
  • Differential test function, validity, independent assessment and report

Technology was certainly not CMS’s MA RFI’s only focus. Other components including health equity, MA plan design, HCV, and market dynamics will be covered in depth in the future.

Laura Beerman is a staff writer for HealthLeaders.

Sharon D. Cole