Month: September 2020

There are several critical considerations for payers looking to build top quality, high-performing and competitive Medicare Advantage plans.

Communication is Key to Success for Acquiring and Retaining Medicare Advantage Members

Ongoing communication is critical to successfully address members’ needs.

“Open Enrollment gives Medicare Advantage (MA) members the opportunity to experience their health plan and decide if another plan better meets their needs. Loyalty to a new plan is tested by these early experiences. This makes it more important than ever that health plans ramp-up the educational efforts to clearly communicate their benefits to help members make the right choice for them initially.” – Deft Research.

Communication needs to be bidirectional, and the ability to stimulate this engagement is imperative. For MA members, satisfaction increases when they feel well-informed and engaged in their healthcare process.

This is also true for healthcare organizations. Silos still affect payers’ and providers’ ability to maximize interdisciplinary approaches to complex issues. It’s the old adage, “One hand doesn’t know what the other hand is doing.” All the data in the world cannot reduce duplicated efforts or missed opportunities to engage the provider or MA member. Payers must provide real-time, actionable data to their MA provider networks and the providers must use the information to improve patient outcomes, leverage new reimbursed benefits and lower costs.

Supplemental Benefits are a Necessity to Managing Social Determinants of Health

Payers and providers are making it a top priority to tackle social determinants of health (SDOH) for better population health outcomes. Many MA health plans have taken advantage of CMS rules regarding new reimbursements addressing SDOH by introducing supplemental benefits and that address “whole life care” and not just short-term medical needs.

Ultimately, addressing SDOH can help minimize or eliminate gaps of care, especially for high-risk, high-cost MA members.

How do you address these disparities? Offer care at the local level. Plans offering care solutions that address isolation, food insecurity and environmental factors impacting chronic conditions help provide MA members with alternative solutions and community resources to fill care gaps. Simple solutions such as carpet cleaning and air conditioners for asthmatics, Meals on Wheels for isolated seniors, and transportation to doctors’ appointments make a material impact on quality of life, as well as overall well-being for large demographic groups. Medicare Advantage plans need to empower their members to engage with new supplemental benefits and create benefits for SDOH that are left unaddressed.

Is Technology the Silver Bullet?

From interpreting data to improving patient engagement, technology plays a meaningful role in building a successful MA plan. The implementation of AI, voice assistance, telemedicine, and other technology also requires the consideration of member communication, readiness for change, and lasting, meaningful engagement. Leveraging automation and data to deliver impactful care pathways is not one size fits all. Though AI is still in the early stage of use in healthcare, the potential impact is promising. The ability to incorporate new, alternative benefits rapidly in response to member needs and changing regulations also requires a modern technology infrastructure.  Payors who cannot keep up with constant change will inevitably be left behind.

I’m excited to see how Medicare Advantage plans continue to improve care and create new opportunities for their members.

For health plans with limited resources, cost pressures continue to weigh heavy. Outdated technology and siloed systems can adversely impact operational efficiency, create significant processing challenges, drain productivity, and ultimately impact the bottom line.

Health plans require analytical insight into the business in order to identify trends and make well-informed decisions. However, the data is often on separate legacy systems with varying data structures, making it difficult to merge data for month-over-month, year-over-year analytics across the portfolio.

The ability to provide robust, comprehensive data to customers and trading partners can be an enormous challenge for health plans.

For example, I worked with a regional plan in the Mid-West with Commercial, Individual, Medicare Advantage, and Medicaid lines of business.

The plan wanted a way to track claims applied to member deductible (Out-of-Pocket), see the specific authorization used when the claim processed, and calculate how many visits a member has used on a limited service such as physical therapy without counting line-by-line. They also wanted a way to easily share that information as well as simplified balance due, credit amounts, and other billing details with their members.

The plan’s legacy platform did not offer a reporting solution with real-time operational insights. Instead, their reports included old data that was useless when trying to provide meaningful information. Not all information in the system was effective date-driven, and some critical data was only point in time, resulting in financial errors and incorrectly processed claims.

Without complete, robust, and accurate data, all in one system, errors will continue. Health plans need a reliable system that is easy to maintain and provides operational data for reporting and analytical dashboards to make critical business decisions.

To successfully compete in today’s market, health plans need next-generation technology and access to real-time analytics that provide insights that enable transparency inside and outside their organizations.

Ever have the kind of day where you wish you could go back and start over? Press reset so you could avoid the errors you made the first time around? Unfortunately, that is impossible, yet thinking about it can provide some insights out how to move forward and make changes in the real world.

Take the healthcare industry, for example. What would a do-over look like if we had the opportunity to go back in time and make different choices? If one could wipe the current slate clean, how could we build a better, more productive, and efficient healthcare system?

Fee-for-service reimbursement is one stand-out do-over opportunity. People took each step thinking it was the right thing to do. Interventions designed to solve one problem layered on top of other interventions designed to solve other problems, without consideration on how they would impact the system as a whole.

Fee-for-service reimbursement models have resulted in several developments that merit a do-over:

• “Sick-care” rather than Healthcare- The incentives associated with fee-for-service reimbursement caused our system to ignore people until they were “patients.” No symptoms, no illness, no service. The culture focused on treatment to the near exclusion of prevention.
• Another artifact of fee-for-service, healthcare delivery fractured into specialized components between which there was little, if any, communication. Higher reimbursements for specialty services meant each patient engagement generated revenue. Each specialist treated their patient in a silo. The problem is that patients aren’t silos.
• Treating disease, or proactively preventing it, is more of a science. The data proving benefit of treatment fidelity and lack of variation is there. For years, the concept of evidence-based medicine was eschewed by many providers.
• The development and proliferation of IT systems that can’t communicate with each other.
• The advent of an adversarial culture between providers and payers rather than one based on cooperation and collaboration.
• The creation of a system that makes it all but impossible for consumers to identify and compare the cost and/or quality of services provided.
• Zero incentive for providers to proactively engage with patients around chronic disease treatment and/or management.

Sometimes it seems going back in time is the only way to fix a problem that’s been generations in the making. On the bright side, the advent of outcomes-based reimbursement and value-based models has started to shift this dynamic. Collectively, we are moving towards an improved system based on quality, outcomes, and shared risks.