Improving Your Medicare Advantage Strategy
Medicare, created in 1965 with an original budget of around $10 billion, now requires around $644 billion to provide healthcare to 60.6 million beneficiaries. The government-sponsored program will account for a projected 18 percent of total federal spending by 2028. Over the past couple of decades, Medicare Advantage has evolved from traditional Medicare plans as a proven alternative strategy to reduce healthcare costs, improve choice, ensure quality and share risk.
In 2021, Medicare beneficiaries will gain access to an average of 33 Medicare Advantage plans, out of the 3,550 Medicare Advantage plans available nationwide — the largest number of plans since its inception. Over a third of all Medicare beneficiaries enroll in Medicare Advantage, and analysts expect a steady increase as the aging population becomes more accustomed to private payers.
For health systems participating in Medicare Advantage, the financial risks transfer from the government to providers. Medicare Advantage provides major health systems the option to switch from fee-for-service Medicare and take control of a larger portion of the premium to capture more value. The government pays more money upfront, with the burden placed on providers to control patient care, and therefore patient costs. The more members who stay healthy and avoid expensive hospital stays, the more significant the shared savings.
“In my opinion, Medicare Advantage isn’t necessarily insurance, it’s wellness,” says Roy McConnell, Executive Lead of MyTruAdvantage, a Medicare Advantage plan provider founded by doctors and hospitals. “Our job is to keep members healthy through partnerships that are community-focused, along with local care. It’s extremely powerful.”
Engaging and Supporting Patients, Healthcare Providers
McConnell believes a better Medicare Advantage strategy includes engaging and supporting both beneficiaries and the healthcare system. MyTruAdvantage is owned by four different health systems with an established history in the community, which helps them understand and care for the local population.
“Our strategy includes engagement, which means providing the best care possible for our patients, at the best time and for the best cost,” McConnell says. “It’s our job to take care of our elderly population, as either an insurance company, a health system or a community. The reality is it takes all of these.”
Similar to traditional Medicare, Advantage plans and providers must meet different quality measures designed with patients’ best interests in mind. Some of these measures include steps to close gaps in care, such as required screenings, vaccines and tests. In addition to preventative measures, managing chronic care and customer service for members impacts the overall rating plans receive, as well as the rate of shared savings.
“There are certain quality measures you need to hit in order to receive shared savings,” McConnell says. “Your star rating influences not only your reimbursement, it indicates to beneficiaries you are a plan doing the right things for patients.
“If you are closing the care gaps, with services such as annual visits, mammograms and colonoscopies, then chances are you are going to have better outcomes for your patients,” he says. “Again, our job is to keep your members healthy.”
Improving Patient Outcomes Throughout the Care Continuum
Patients’ care often doesn’t end once discharged from an acute care facility. Similarly, the financial risk associated with a patient continues, as Medicare can penalize health care systems if readmissions rates for certain conditions exceed the national average. Managing a successful Medicare Advantage strategy requires providers stay connected with the patient throughout the recovery process.
“When I worked for a hospital and a patient left our facility, it was almost like they went into the abyss,” McConnell says. “To best manage that population, I need to know where they are throughout the entire episode of care. Once I found Olio, I gained sight beyond sight.”
McConnell explains the software solution allows him to see and address care decisions for patients he didn’t previously have visibility into after discharge from the acute care setting. A system’s Medicare Advantage strategy should incorporate actively lowering readmissions rates through a variety of efforts, including clearly communicating patient discharge instructions to all parties involved, coordinating with patients’ primary care physicians, and collaborating with post-acute care providers.
“One of the things I love about Olio is the escalation feature that’s tied directly to my phone,” McConnell adds. “A medical director can reach out and give us a chance to intercede and help, before the patient is sent back.”
Sustaining a Mutually Beneficial Medicare Advantage Strategy
As a younger sector of the population ages into the Medicare program, their healthcare needs and wants differ from older generations. Sustaining a Medicare Advantage strategy requires continually assessing your plan population and the health systems providing care.
“Not only is Medicare Advantage growing, but the population aging into it is also growing,” McConnell says. “We’ve been surprised to find gym memberships are important to them. This group is technologically savvy — they’re on Facebook and Instagram.”
McConnell’s team focuses on building membership, as well as developing the type of ideal members. “If you have a small membership, you can really have some cost barriers,” he says. “Economies of scale build the appropriate level of risk-based revenue, and the best mix of characteristics for our patient population.”
Defining success means assessing the plan, membership, continuous value, and quality improvement throughout the continuum of care. Smart plans result in improved performance, which rewards patients and healthcare providers by delivering the right care at the right time and in the right place.