MA provides post-acute discharge care


More Medicare Advantage Plans Offering Post Acute Care

The growth in Medicare Advantage (MA) enrollments since the adoption of ACA in 2010 has been nothing short of remarkable. The number of registrations in these plans has doubled since the adoption of the law despite significant reductions in payments to the MA plans incorporated into the law. The convenience of the baby boom generation with managed care, along with a restructured bonus payment system, has driven unabated growth since 2010 – and there is no end in sight. Masters enrollment is expected to increase to between 42% and 50% of total Medicare enrollment over the next decade, with steady growth expected for the foreseeable future. In addition, increased demand stimulates supply. By 2019, Medicare beneficiaries will have 20% more plans to choose from nationwide – over 3,700 plans – and new market entrants have made aggressive bets on AD growth.

As the plans enter and expand into their AM markets, however, they will face changes in pricing and benefit design. The demands of competition will drive more markets to zero-premium policies, a competitive dynamic already common in markets heavily penetrated by managed care. The growth of these policies, in turn, will increase the pressure to design and deliver broader benefits that take a more proactive and holistic approach to providing care and maintaining health. Meanwhile, MA plans are under relentless pressure to earn a four or five star rating, as high ratings are essential to staying competitive.

MA plans are aware of these dynamics. Large national payers have bought and built capacity in post-acute and palliative care, services that were previously an afterthought for many MA plans, if they thought about it. Additionally, third-party providers have emerged to enable AD plans to manage the post-discharge care journey more rigorously and efficiently. Such investments are essential. The variability in spending on post-acute care services accounts for about 75% of the total per capita variability of the Medicare program. Any effective and sustainable strategy in a zero premium environment requires thoughtful and effective interventions to reduce variability.

Treat non-clinical factors

As plans and providers work together to manage post-discharge care, they will also need to consider non-clinical variables. Limitations in the performance of activities of daily living (ADLs) and social determinants of health have as large an impact on health expenditure in the elderly as the presence of chronic diseases. These types of variables are addressed more effectively during the transition to and while care is provided there.

Mitigating the adverse health effects associated with decreasing ADLs and social determinants of health requires services and interventions that Medicare has not traditionally paid for. But, recognizing that rapidly aging Medicare beneficiaries require a holistic approach to health, CMS authorized MA plans to offer unqualified services as part of their plans for the first time in the 2019 benefit year. These personal care and private service can be essential in keeping Medicare beneficiaries healthy and at home.

The mere fact that MA plans continue to develop post-acute care networks provides the plans with a vehicle to introduce new benefits and innovative designs.

The timing for this new category of benefit is fortuitous, as it will build on the investments in post-acute care that AD plans have made in recent years. MA plans have built (or soon will need to build) flexible platforms that allow them to provide skilled and unskilled home-based services, all in the service of enlisted health and avoiding need hospital care and other expensive parameters.

Lifting satisfaction

The actuarial uncertainty surrounding these new benefits probably means prudent use of this new category of benefits at the outset. As MA plans progress, the effects are likely to have a greater impact on patient satisfaction than on outcomes. Nonetheless, the mere fact that MA plans continue to develop post-acute care networks provides plans with a vehicle for introducing new benefits and innovative benefit designs into their plans. Will the new benefits mean more MA plans start charging premiums? Probably not in the short term, as it would put them at a competitive disadvantage. Plans that choose to offer the new benefits will have to do so as an investment in the health of their registrants – and if it works, it should positively impact costs and put downward pressure on premiums. If this does not work, then plans will be faced with the choice of recouping their investment by increasing premiums, reducing benefits or, the best option, finding ways to ensure that the additional services have the desired effect of improving performance. health of registrants. .

It is striking how the rapid growth in master’s enrollment and increasing competition for these grantees has created a strong market for innovation in the design and delivery of a 35-year program. Over time, the ability to compete in zero-premium markets will require MA plans to provide care to address all of the risk factors that affect a patient’s use of healthcare resources and increase. the chances that people can live full and independent lives for as long as possible.


Erik Johnson is Vice President and National Practice Leader for Value-Based Care at Optum.



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