HJNO Jan/Feb 2025

HEALTHCARE JOURNAL OF NEW ORLEANS I  JAN / FEB 2025 43 community as it will in the urban com- munity. So, the MA plans have no reason to steer [patients] and cut them out of the community,” said Barr, indicating that Fed- erally Qualified Health Centers now receive separate supplemental funding to help cover their costs and that a similar mecha- nism should help CAHs survive. Barr also argued for policies that pro- hibit the use of MA prior authorization in rural areas, explaining that these adminis- trative burdens distract from patient care improvements. GATHERING DATA During a March 2024 meeting, MedPAC officials announced plans to study MArural access challenges. The group discussed the extent to which MAplans hasten rural hos- pital closures and concerns with MA net- work adequacy. “We want to know if rural MA [beneficia- ries] tend to travel longer for care or if MA plans actually encourage the use of local care,” said MedPAC Principal Policy Ana- lyst Jeffrey Stensland. 29 MedPAC also discussed MA enrollees who switch back to traditional Medicare. “People get into these [MA] plans, and then realize they don’t have the access,”Barr said during a recent interview. “I sign up. I’m 65 in good health. Ten, 20 years later, I’m driv- ing 70miles to get care. I’m exhausted. Then, they want to go back to the rural hospital to get their care there. At that point, their cost of Medigap is high. It’s going to cost you even more than it did before you went into MedicareAdvantage, and maybe a lot more. If you’ve got cancer or something, they can charge you for your preexisting condition.” MedPAC also said it plans to continue exploring rural providers’ frustration with prior authorization burdens and “the extra effort and time it takes to be paid from MA compared to fee-for-service.”Barr recently said she would like to compare how MA plans and MACs process the same rural provider requests. KFF found that MA plans overturn 8 out of 10 appealed denials. 30 Providers have argued these results showMAplans misuse prior authorization as a cost-containment tactic that lacks medical justification and jeopardizes patient outcomes. 31 Despite a 2024 CMS final rule designed to “ensure people with MA receive access to the same medically necessary care they would receive in traditional Medicare,”Lou- isiana providers have continued reporting harmful care delays. 32, 33 “I can tell you that in five years of having inpatient rehab, Humana denied over 90% of the requests for prior authorization,”said FranklinMedical Center CEO Blake Kramer. After pledging aggressive auditing, CMS has not announced any enforcement actions against noncompliant MA plans. Making matters worse, KFF researchers found that CMS lacks sufficient data to “determine whether plans are complying”with the 2024 MA rule. 34 “Until there’s an enforcement mechanism that really punishes the plans, nothing’s going to happen,” said Kramer. “They’ll keep doing it until they’re fined or have their contract with CMS revoked.” IMPROVING RURAL OUTCOMES As leaders explore growing access bar- riers for rural MA patients, both Pratt and Barr expressed optimism that rural provid- ers can be key partners in improving future patient outcomes. Barr said she previously led a national rural ACO in 44 states and Guam with hundreds of rural hospitals, including SJPH, and more than 10,000 rural doctors. Barr said the group helped tradi- tional Medicare save $500 million by rally- ing around “providing better quality, better access and being proactive in their care. This is why they were in medicine.” n REFERENCES 1 https://www.sjph.org/awards-accolades/ 2 https://www.cms.gov/medicare/payment/fee-for- service-providers/shared-savings-program-ssp-acos 3 https://www.sjph.org/services/primary-care/ 4 https://youtube.com/watch?v=WgOnWrablfI 5 https://www.law.cornell.edu/cfr/text/42/422.116 6 https://www.govinfo.gov/content/pkg/FR-2020- 06-02/pdf/2020-11342.pdf 7 https://www.kff.org/medicare/issue-brief/ medicare-advantage-enrollment-plan-availability- and-premiums-in-rural-areas/ 8 https://www.cms.gov/Medicare/Medicare- Advantage/MedicareAdvantageApps/Downloads/ MA_Network_Adequacy_Criteria_Guidance_ Document_1-10-17.pdf 9 https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.01435 10 https://www.aha.org/testimony/2024-05-16-aha- statement-senate-finance-committee-hearing-rural- health-care 11 https://www.medpac.gov/meeting/ march-7-8-2024/ 12 https://crsreports.congress.gov/product/pdf/R/ R47526 13 https://www.medpac.gov/wp-content/ uploads/2024/10/MedPAC_Payment_Basics_24_ CAH_FINAL_SEC.pdf 14 https://www.medpac.gov/wp-content/ uploads/2021/11/medpac_payment_basics_21_cah_ final_sec.pdf 15 https://www.medpac.gov/wp-content/ uploads/2024/03/Mar24_Ch15_MedPAC_Report_ To_Congress_SEC.pdf 16 https://www.wbrz.com/news/rural-towns-at-risk-a- quarter-of-louisiana-s-rural-hospitals-vulnerable-to- closure-study-finds/ 17 https://www.shepscenter.unc.edu/programs- projects/rural-health/rural-hospital-closures/ 18 https://www.commonwealthfund.org/publications/ explainer/2024/mar/how-government-updates- payment-rates-medicare-advantage-plans 19 https://www.kff.org/medicare/issue-brief/ medicare-spending-was-27-percent-more-for- people-who-disenrolled-from-medicare-advantage- than-for-similar-people-in-traditional-medicare/ 20 https://www.kff.org/medicare/issue-brief/ medicare-advantage-in-2024-premiums-out-of- pocket-limits-supplemental-benefits-and-prior- authorization/ 21 https://www.kff.org/medicare/issue-brief/a- snapshot-of-sources-of-coverage-among-medicare- beneficiaries/ 22 https://paragoninstitute.org/wp- content/uploads/2024/02/Albanese_ ImprovingMedicareThroughMedicareAdvantage_ FOR-RELEASE-V4.pdf 23 https://www.medpac.gov/wp-content/ uploads/2024/03/Mar24_MedPAC_Report_To_ Congress_SEC.pdf 24 https://www.chartis.com/sites/default/files/ documents/chartis_rural_study_pressure_pushes_ rural_safety_net_crisis_into_uncharted_territory_ feb_15_2024_fnl.pdf 25 https://lhaonline.org/Common/Uploaded%20files/ About/Links/RIL24821.pdf 26 https://www.aha.org/system/files/media/ file/2024/03/AHA-Statement-to-House-Ways- Means-Committee-on-Access-to-Health-Care-in- America-Ensuring-Resilient-Emergency-Medical- Care.pdf 27 https://chqpr.org/downloads/CHQPR_Response_ HouseWM_Rural_RFI_October_2023.pdf 28 https://www.medpac.gov/wp-content/ uploads/2024/10/MedPAC_Payment_Basics_24_ CAH_FINAL_SEC.pdf 29 https://www.medpac.gov/wp-content/ uploads/2023/10/March-2024-meeting-transcript. pdf 30 https://www.kff.org/medicare/issue-brief/use- of-prior-authorization-in-medicare-advantage- exceeded-46-million-requests-in-2022/ 31 https://www.ama-assn.org/system/files/principles- with-signatory-page-for-slsc.pdf 32 https://www.cms.gov/newsroom/fact- sheets/2024-medicare-advantage-and-part-d-final- rule-cms-4201-f 33 https://www.beckershospitalreview.com/finance/ unnecessary-medicare-advantage-denials-harming- louisiana-patients-crowding-our-emergency- departments-and-costing-u-s-providers-billions.html 34 https://www.kff.org/medicare/issue-brief/gaps- in-medicare-advantage-data-remain-despite-cms- actions-to-increase-transparency/