The healthcare system and ecosystem is in a period of great change as we shift from pay per service to pay for value. As the nuances of federal and state policy continue to evolve we need to keep the following principles in mind especially for the sake of our nation’s seniors:
Focus on needs and preferences of seniors as consumers
Seniors deserve choice, a satisfying experience and the support to achieve their optimal health. As the fastest growing consumer segment, they will demand it and get it or seek alternatives. Alternatives could be a different health plan, hospital, doctor, other service provider or site of care. Choice is not limited to hospital and provider network. Choice means if, where and how they get treatments, what type of treatment and at what cost financially and to their quality of life. A satisfying experience doesn’t mean a satisfactory experience. It means an experience that is satisfying to them; did it meet or exceed their expectations in terms of ease of access and use, courtesy and knowledge of their health care team members and did they achieve their optimal health outcomes. Furthermore optimal health is different for every senior and their view of optimal health must be understood, respected and supported.
As 10,000 baby boomers per day age into Medicare, these principles and the need to deliver on them doesn’t disappear. In fact the need is amplified as according to the Council on Aging 80% of older adults has at least one chronic conditions with 68% having two or more1 and 9 of 10 take at least one prescription and depending on the source up to 27-29 prescriptions per year 2,3. Furthermore, their desire to age better and remain in their homes longer than previous generations 4 while on average living longer will take proactive self- management skills, sophisticated and comprehensive care management and leveraging of data insights and innovative solutions that support independence.
Approach payers with engaged providers as purveyors of population health management vs payer of claims
In addition to the market pressure of consumer demand, cost of care continues to place a burden on society as a whole. Traditional self- insured employers, health plan and at risk providers have evolved from payers of claims to purveyors of population health management. A population health framework includes up front data analytics and in person assessments to understand the population and individual; risk stratification; pairing the right interventions in a timely manner based on risk and individual need and preference, supporting self- management skills care coordination including in chronic conditions and through transitions of care and measuring and improving outcomes.5
In both Fee for Service Medicare and Medicare Advantage CMS is supporting advancement of quality outcomes through numerous demonstrations and programs that provide bonus incentives for plans e.g. Star Ratings and penalties for providers e.g. reduction of payments when readmissions exceed national averages. However, population health by definition requires much more than tracking quality metrics or providing more benefits that seniors have to seek and pay for 6. As seen in most Medicare Advantage plans, it is the overarching approach to promoting holistic consumer centric services that improve or maintain health and avoid unnecessary costs and quality of life setbacks. 7,8 Value based care arrangements have also expanded among commercial payers through contracting for value or supporting provider lead models with the building blocks necessary to assume financial risk.
Advance comprehensive, cost effective benefits through expertise, infrastructure and scale
The number of seniors enrolling in a Medicare Advantage has increased to roughly one third of the total 57 million beneficiaries enrolled in Medicare9 and most plans likely due to a combination of more benefits to include dental, vision and hearing but also because of the approach described above. Most Medicare Advantage Plans have invested substantially in the infrastructure to go beyond administering the benefit to provide full service population health management programs for the group of seniors for which they have accountability. In their direct employ or through a delegated partner they have engineers, data management experts and senior scientists transforming data into useful insights about the population and individual’s needs. They have a range of clinical and nonclinical navigators, coaches and care and case managers working directly with consumers to access the best, most cost efficient care as well as support tools and programs to optimize their health. Finally, quality experts produce and review metrics to share with programs leads and engage providers in value based care models in an effort to continually innovate and enhance solutions aimed at improving outcomes for the individual and population as a whole.
Effective population health management requires not only expertise and experience but the scale to spread the cost of these programs over a large number of lives. This explains in part the ability of Medicare Advantage plans to offer more programs and services for seniors at no added cost and in turn why seniors continue to enroll in Medicare Advantage programs at increasing rates.
Ensure sustainable policy and program models-our job as leaders
As health care leaders it is the job to see that Medicare is funded at a level and in a design that can sustainably through smart cost management strategies support our growing number of seniors. Not surprisingly supporting seniors in their goals is often times more cost effective. Remote monitoring in the home and some self- care help to keep them in the environment they choose is much less expensive than institutional care. Transportation while not “medical care” provided to attend a doctor’s appointment is much less costly than a missed appointment that results in a complication and hospital stay.
The examples above and many others form the underpinnings of population health tailored to the individual senior’s need and the foundational elements of sustainability i.e. quality effective, cost efficient and desirable. By providing service beyond benefit administration to include the principles and infrastructure to support population health management and value based programming, we can honor our seniors by delivering preferred, high quality options for optimizing their health and lives.
- Council on Aging. Chronic Diseases. https://www.ncoa.org/healthy-aging/chronic-disease/Website accessed February 20, 2017.
- Home and Community Preferences of the 45+ Population. AARP. November, 2010. http://assets.aarp.org/rgcenter/general/home-community-services-10.pdf
- Many Seniors Take Too Many Medications –Here’s How to Fix It http://www.forbes.com/sites/matthewherper/2014/12/10/many-senior-citizens-take-too-many-medicines-here-are-three-fixes/2/#2aab4b912511. Accessed February 20, 2017.
- Medicare HMOs Fact Sheet. http://www.medicarehmo.com/factsheet
- Population Health Alliance-Understanding Population Health http://www.populationhealthalliance.org/research/understanding-population-health.html. Accessed February 13, 2017.
- CMS Chronic Care Management Services-How is it covered? https://www.medicare.gov/coverage/chronic-care-management-services.html Accessed February 13, 2017.
- Maximizing Medicare Advantage https://www.humana.com/about/public-policy/humana-improves-healthcare/strengthening-system/maximizing-medicare-advantage Accessed February 13, 2017.
- How Original Medicare and Medicare Advantage Differ. http://www.bcbsm.com/medicare/help/faqs/works/difference-original-medicare-advantage.html
Accessed February 13, 2017.
- BMA: MA Enrollment Update: Beneficiaries Continue to Choose Medicare Advantage. Issue Brief: July http://bettermedicarealliance.org/sites/default/files/BMA_MA_Enrollment_Issue_Brief_July_2016.pdf Accessed February 20, 2017