Actionable Insights for the Next Era of Medicare Advantage

The Medicare Advantage (MA) program, as we know it today, celebrated its 21st birthday this year. Its teenage years saw significant growth in program benefits (like zero copays, vision and dental benefits, transportation, etc.) but also more hoops for members to jump through in order to access those benefits (like prior authorization, step therapy, and referral requirements).

Call it a crossroads, call it growing pains – but as MA enters its third decade, health plans offering MA plans may need to tweak their formula for success for several key reasons:

• Plan reimbursement by CMS won’t likely rise in line with underlying healthcare inflation.
• Risk adjustment programs that reimburse plans according to the member’s health may not continue in a predictable manner (if at all).
• Payers may be unable to control medical costs through traditional care and utilization management models.
• Generous benefits alone (regardless of their utilization by members) won’t likely yield sustainable growth.

Payers should prepare for the following:

• Ongoing cuts in MA funding requiring plans to think more strategically about the cost of benefits.
• Ongoing CMS scrutiny and changes to the risk-adjustment and quality bonus programs, to ensure they achieve the program’s goals.
• A tighter fiscal environment in which plans will need to rethink their role and ability to manage the complex set of health conditions (especially conditions requiring speciality care) that drive medical expenses.
• Members spurning plans that make it difficult to access benefits – especially supplemental ones.
• Growth that’s driven more by member retention than purely new-member acquisition, and as a result, an increased need to deliver personalized and high-quality care experiences.

One needs only to scan recent industry headlines to find examples of plans that have awakened to the painful early signs of the above trends. One can also see examples of forward-thinking plans preparing for a new basis of competition – one grounded in personalization, experience, and value.

Payers tactics will point to what MA will look like in its third decade

• Personalized benefits and services for members, primarily via value-based care specialty navigators who engage patients more deeply in their treatment plan, increasing the odds of clinical success.
• An outsized focus on the value these and similar benefits and services create for members based on their health needs, preferences, and lifestyle.
• Deep partnerships within local delivery networks, both to engage with patients as early in their care journey as possible and to match them with the most appropriate providers based on their needs.
• Information sharing across the ecosystem – helping PCPs offer great care while also helping patients navigate a payer’s programs and services.

While the above prescription for success may be easy to describe, it requires a fundamental shift in execution for health plans. Some are further along than others in this journey.

To be successful, plans should take a clear-eyed view of their ability to execute this on their own because, for many, it will make much more sense to partner with companies that have helped plans achieve these goals.

How this works for TailorCare

At TailorCare, we are fortunate to work with health plan partners at the vanguard of this change. We are purpose-built to partner with payers to better serve their members, base on the premise that providing expert specialist navigation to patients at the right time in their care journey can produce better outcomes and experiences, delivering lower medical costs for payers.

Given the significant complexity patients face in managing these conditions, we focus on musculoskeletal (MSK) issue and the coordination challenges and burdens placed on PCPs, specialists, and payers in delivering care to musculoskeletal patients.

At TailorCare, we provide highly-trained clinical navigators who understand the range of MSK support available to patients and have the singular focus of investing time and care to help patients find the ideal treatment option.

By engaging patients early in their care journey, we ensure they get the right care from the right provider at the right time. Our model demonstrates that it is possible to positively influence cost and quality by engaging patients early and patients have a better experience (our current NPS score is +94).

Looking at this another way, payers who adopt similar strategies show – and not just say in empty marketing-speak – that they are committed to helping their members meaningfully navigate and access their benefits. At the core of this process is a commitment to helping members find quality providers and, perhaps more importantly, the exact providers they need based on their clinical indicators, preferences, and personal circumstances.

At the same time, it demonstrates an authentic commitment by the payer to its members having a great experience across the entire care journey, making it far more likely that members will stay with their health plan for life.

While models like TailorCare are not a panacea for the myriad challenges facing MA plans, they’ve proven that the industry’s challenges are not intractable. Plans can indeed create better experiences for their members while at the same time engaging their care delivery partners in new, non-abrasive ways, improving the outcomes for patients, and likely impacting the cost to serve this population.

Partnerships like ours demonstrate the deep and lasting value plans can be created through common sense models – models that don’t require significant (if any) disruption to health plan operations while enabling them to compete in new and essential ways. In so doing, they will be far better positioned to serve their members in Medicare Advantage’s third decade, and beyond.