Medicare Advantage on the Rise

Medicare Advantage on the Rise

Continued growth, strong performance and new guidelines are good news for plans and their members

Already the choice of more than one-third of the 59 million people with Medicare, the Medicare Advantage (MA) program is growing and changing in ways that will help even more seniors maintain good health and independence as they age.

Strength in Numbers

The number of eligible seniors opting for MA plans over fee-for-service Medicare has grown year after year — and shows no signs of slowing down. Medicare managed care plans now provide coverage to more than 21 million people with another 2 million expected to join in 2019. If that happens, MA plan members will represent 39 percent of the total Medicare population.

Among the largest MA plans in California, SCAN has witnessed this trend first-hand, increasing market share and experiencing significant growth in Los Angeles, Orange and Sonoma counties during the 2018 annual enrollment period.

Bigger and Better, Too

MA plans improve the health of seniors in ways that other coverage options haven’t, and this is fueling increased enrollment. With a focus on preventive services, care coordination, access and continuous improvement, MA plans continue to outperform fee-for-service Medicare in key quality measures. A recent study by Avalere Health shows Medicare Advantage beneficiaries had 23 percent fewer inpatient room visits and better health outcomes overall than individuals enrolled in FFS Medicare at similar costs to regular Medicare. People with chronic conditions, such as diabetes, in particular benefit from the extra benefits and programs available through Medicare managed care, experiencing better health outcomes and fewer complications, including serious complications, from their conditions.

Findings like these are important for several reasons. For one, they confirm that what providers of MA plans like SCAN and others like us are doing is making a meaningful difference in the lives of members, particularly those who need help the most. They also underscore plan’s commitment to providing high quality benefits and services that meet members’ individual needs related to health and independence.

Knowing that MA plan members have better experiences can also be useful to our broker partners, because when you present an MA plan to your clients, you can be confident you are offering them coverage they can rely on for high-quality care, improved access and better health. When it comes to MA, quality begets even greater quality. Since Medicare pays a bonus to plans demonstrating the highest quality, well-performing plans can reinvest these bonuses, continuously improving benefits, access and quality of care for the member.

SCAN’s 4.5 star rating for 2018 from the Centers for Medicare & Medicaid Services is not only a reflection of our efforts to improve quality and services, but an investment that pays off in a meaningful way for us, our provider partners, and our members.

New Laws, New Opportunities

A’s success in providing high-quality, value-driven and cost-effective care has not been lost on lawmakers. At the federal level, MA plans have earned bipartisan support, with more than 360 members of Congress pledging to preserve the program. They showed their support in an even more tangible way earlier this year with legislation that will make it possible for plans to further improve services and health outcomes: Special Needs Plans, which until now were temporary demonstration projects, can now be offered by MA plans on a permanent basis. This change will allow more of the nation’s frailest seniors to benefit from programs that help them age successfully at home for as long as possible.

Health plans that already offer SNPs can begin to think in the long term, while other plans that were put off by the uncertainty of past SNP rules will likely begin exploring these options. The result: More seniors with chronic illnesses and other special needs will have access to programs and services
designed to support them.

The definition of “primarily health related” supplemental benefits has been expanded to allow MA plans to offer food, counseling and other nonmedical services as long as they can help prevent, cure or reduce illness or injury. TeleHealth made headlines when the Bipartisan Budget Act was signed into law in February. The legislation allows MA plans to include delivery of telehealth services in a plan’s basic benefits. This can enable a member to access mental health services from the privacy of their own home, or provide a convenient way to ensure post-hospitalization follow-up care is received.

While plans in the past have been required to offer the same benefits to all their enrollees, new regulations also allow MA plans to tailor benefits to groups within their membership with specific health conditions. For example, a plan could offer all members diagnosed with diabetes additional coverage for podiatry services, offering another way to better tailor plan coverage to member need. Many MA plans have likely incorporated the new benefit flexibility into 2019 plan bids for approval by Medicare.

While 2019 benefits have not been released as of press time, I’m confident that many in our industry are thinking of new and creative ways to provide the most value for members under the new guidelines.

A Strong Choice for Seniors

These “new developments” align with SCAN’s history as a social HMO and our decades of experience caring for the frailest seniors. As a long-time advocate for changes that would allow greater flexibility in meeting seniors’ individual needs, we are excited to be looking at ways to once again provide benefits that can more directly help each member age safely in the setting of their choice.

When evaluating which MA plan is right for each client, think about both the nature of the benefits and the stability of the plan. While it’s exciting to offer “more” and “different” benefits, it’s also imperative that the plan will be there for the long-term. Make sure the plan under consideration is adding benefits and services at prices that are sustainable year over year. While more customized coverage options will only add to MA’s appeal, plan members— your clients—depend on stability of cost and coverage.

The plan should work as hard to retain existing clients as it does to gain new ones. The bottom line is this: 2018 has been a good year for seniors! The many benefits that already come with membership in a Medicare Advantage plan will inevitably get even better.

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website


Medicare Advantage – Plans need Effective Risk, Quality and Care Strategies

Medicare Advantage – Plans need Effective Risk, Quality and Care Strategies

Licensed Medicare insurance brokers provide invaluable guidance for retirees making healthcare coverage decisions that can have serious consequences on their health and financial well-being. Therefore, it’s critical that they have a firm grasp on trends, innovations and helpful solutions in the Medicare Advantage (MA) space. First of all, the nation’s untenable rate of healthcare spending has sparked a growing reliance on MA plans, which provide an alternative to traditional fee-for-service (FFS) Medicare.

In fact, MA plans now represent 30.6 percent of all Medicare enrollees and 28.9 percent of Medicare’s 2017 gross spending budget. Second, individuals can get Medicare benefits from original Medicare or a MA plan, such as an HMO or PPO. With the former, the government pays for Medicare benefits. With MA plans, the coverage is offered by private companies approved by Medicare.

MA plans provide all Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage. The Best Possible MA Plan, The most effective MA plans on the market look at the full spectrum of the patient and apply an end-to-end solution. When done effectively and efficiently — and combined with payment reform — it’s possible to enhance care coordination using analytics, in-home care, retrospective solutions and care management to significantly improve outcomes.

Value-based contracting generates cost efficiencies and improves clinical outcomes in MA. For MA plans and risk-bearing entities to remain sustainable, however, they must adopt innovative quality and risk adjustment programs to meet the growing demand for effective care strategies. For example, MA plans can gain clinical insight into risk-adjusting conditions to enhance their traditional analytical platforms.

How Does a Risk Adjustment Model Work?

Risk adjustment is an actuarial tool used to calibrate payments to health plans based on the relative health of the at-risk populations. If insurers are limited in the extent to which premiums can vary by health status or other factors that are associated with health spending, risk adjustment can help ensure that health plans are appropriately compensated for the risks they enroll.

Significantly, most claims in fee-for-service Medicare are paid using procedure codes, which offer little for providers to record more diagnosis codes than necessary to justify ordering a procedure. In contrast, MA plans have a financial incentive, since the current risk adjustment model was introduced, to ensure that their providers record all possible diagnoses because higher enrollee risk scores result in higher payments to the plan.

Consider two examples of how an MA plan can be optimized: Advantmed’s Physician Record Review (PRR) is a two-stage retrospective chart review process from a 1) certified coder and 2) board-certified physician. Advantmed’s Prospective Health Assessments (PHA) provide a robust view of members and their care needs.

Providers can also rely on PHAs to lay the groundwork for developing more accurate reporting documentation, improving patient engagement and compliance, enhancing disease management and reducing utilization. This kind of full-spectrum, end-to-end approach to care helps providers identify gaps in care and manage plan members more productively. It also helps health plans that are serving as intermediaries, executing solutions and assuming risk.

Ultimately, the greatest benefit goes to the plan member, who will be guided toward more preventive care and self-management early in the care process. Innovative Approaches Value-based contracting can drive
utilization patterns and improve clinical outcomes among chronically ill, elderly MA members. One study tested the hypothesis that payer-provider risk contracting promotes high-value care and concluded that in the future, more clinicians will have to bear the monetary risks associated with healthcare utilization.

The MA program provides a unique milieu for investigating provider groups that have either risk-bearing or fee-for-service contracts with private health plans. Full-risk capitation combined with a revenue gain share agreement sparked a clinical practice transformation at the provider group level, associated with increased office-based care and decreased hospital-based services.

The clinical practice transformation resulted in a 6 percent survival benefit and lowered the hazard of death by 32.8 percent. Value-based contracting benefits all stakeholders The intervention group’s overall survival rate was 82 percent, and the control group’s was 76 percent. This 6 percent survival benefit first became apparent at 16 months after the intervention, coinciding with the first year that the intervention group had higher office-based utilization than the control group.

Age provided a natural time-scale for calculating the hazard of death for this elderly population with multiple comorbidities and a higher risk of all cause mortality. Intervention-group members had a 32.8 percent lower hazard of dying (P <.001). The survival benefit was more apparent among those aged 82 to 96 years. Randomization inference confirmed these survival data, whether time (P <.001) or age (P <.001) was the time scale.

Improved survival is related to and attributable to the Centers for Medicare and Medicaid Service’s (CMS) Hierarchical Condition Category (HCC) data and value-based contracting, which then transform primary care delivery. Brokers should also be aware that CMS expanded how it defines the “primarily health related” benefits that private insurers are allowed to include in their MA policies, with insurers including these extras on top of providing the benefits of traditional Medicare.

For instance, air conditioners for people with asthma, healthy food, rides to medical appointments and home-delivered meals may be among the new benefits offered to Medicare beneficiaries choose private sector health plans, when new federal rules take effect. This means MA beneficiaries will have more supplemental benefits and be better able to lead healthier, more independent lives.

For answers to your pressing questions call Jim Robeson, the Medicare Answer Guy @ (858) 935-9120. Visit website