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GUIDE

How To Differentiate Your Medicare Advantage Plan By Investing In Primary Care Delivery

Healthcare is in a state of accelerated change.

Payers must find a way to adapt and stay competitive amidst rising costs, economic pressures, healthcare reforms, and the effects of the COVID-19 pandemic. In the face of these challenges, there is a way for payers to offer a better member experience and control the total cost of care: by investing in primary care delivery.

For payers in the Medicare Advantage (MA) market, control over primary care delivery is especially important in building a competitive advantage. MA populations are more likely than other groups to be dealing with complex health situations, and some may struggle with navigating the healthcare system to get the care they need.

Payers who want to attract and maintain more MA members need to solve access issues, increase the quality of care, and control cost — and they can, by investing in a better model of primary care delivery. It’s called advanced primary care (APC). APC done right, with the right care delivery partner, helps raise CMS star ratings and offers other benefits for payers, providers, and members.

This page provides an in-depth perspective on how payers can use the APC model to attract and retain members to achieve growth in the MA care market.

Medicare Advantage members have unique
health needs

Here are some relevant statistics to keep in mind:

1 in 3

Medicare beneficiaries enrolled in an MA plan

24 days

Average wait* for a new patient physician appointment
*in 15 of the largest US cities

8 minutes

Average duration of visit with primary care provider

71

Average age of MA beneficiary

4-5

Average number of chronic conditions per patient

37%

Enrollees in large MA plans who have 3 or more chronic conditions and difficulty with a basic Activity of Daily Living

APC solves challenges for Medicare Advantage members

When payers invest in APC for their MA members, they can solve healthcare access issues, reduce overreliance on specialty care, and improve the member experience by focusing on the unique needs of MA patients.

Click the challenge and solution links to expand and learn more.

  Access

Challenge: Limited access to primary care providers

A survey of providers in metropolitan areas shows that in large metro markets, only 85% of physicians accept Medicare. In mid-sized markets, that average drops to 81%. This limits the care options available to MA patients.

Some MA patients can’t access a primary care provider in their area because a specific health system has hired all available providers, leaving other payers with few options to serve their members.

Once MA patients have found a provider, they often wait weeks or months for an appointment. When patients finally get an opportunity to speak to their provider, the average visit lasts only eight minutes. It’s no wonder that a survey of Medicare patients and providers revealed 85% of providers felt they don’t have enough time to address all their patients’ clinical concerns.

This is a major concern for MA populations, who are more likely to be dealing with complex or chronic health concerns that can only be properly addressed with an in-depth conversation.

Solution: APC offers better access and longer appointments

Unlike fee-for-service models that require providers to see a high volume of patients per day, APC is designed to prioritize quality of care. First, APC increases care access by allowing payers to place a care center wherever it is needed, so MA populations won’t struggle to get face time with their primary care provider.

Then, when MA patients come in to see their provider, APC provides them with longer-than-average appointment times. This extra time gives members and providers the freedom to build a meaningful, personal connection and fully address complex health issues.

When payers invest in an APC model, they can ensure that their members will feel heard and understood, not rushed. By creating an experience that is completely different from the typical health appointment, payers can differentiate their MA care plans, provide value, and retain members.


icon_health-plus-specialty-care-star  Specialty Care

Challenge: Over-reliance on specialty care

MA patients are more likely than other populations to have multiple chronic conditions. In a fee-for-service healthcare setting, this means they are more likely to frequently be referred to a specialist for care. Specialty care often comes at a high cost and takes place without involvement from their primary care provider.

Solution: APC allows for more controlled care

In the APC model, MA populations can receive 80-90% of the care they need in the primary care setting. By delivering care that would be referred to specialists in a fee-for-service model, payers can harness the APC model to control the supply chain, rein in over-utilization, and reduce the total cost of care, while still providing the best outcomes.


icon_complexity-buildings-question-confused  Complexity

Challenge: Fragmented, complex care from multiple providers

MA populations who are managing multiple chronic conditions need a care system that is easy to navigate, but their experience with care is often disjointed.

In the traditional fee-for-service model, primary care providers simply don’t have the time and resources to create and oversee individual care plans for each person they treat. No one is looking at the big picture and guiding the patient towards better health.

Solution: APC includes full care coordination

APC gives providers the time and resources they need to create comprehensive care plans, so patients aren’t left to manage their own care. If specialty care is required, primary care providers maintain control over quality and cost by referring to high-value, low-cost specialty networks.

In the APC model, primary care providers coordinate and schedule follow-ups, so that specialty care is integrated into each patient’s care plan for long-term adherence and support.

This makes a huge difference for MA patients. Their primary care team will make their appointments with specialists and bring them back to the primary care center to follow up, answer questions, and help manage medications.

This kind of control has other benefits as well. When primary care providers share relevant medical and other background information beforehand with specialists, there’s no need to duplicate tests. This reduces the waste that often occurs with an overreliance on specialty care.


icon_patient-heart-love-care-value-satisfaction  Member Experience

Challenge: Provider networks aren’t focused on the needs of MA members

For most healthcare plans, a primary care provider’s panel could consist of patients from an unlimited number of payer organizations. This means that providers are less likely to be focused on the unique needs of a given plan’s MA members — aging, chronic conditions, and more. Payers may want to create a better care experience for MA members, but they are forced to work with existing provider networks that serve as a catchall for numerous fragmented populations.

Solution: APC allows payers to tailor the member experience

When payers gain control of care delivery, they can design a custom care system to improve MA members’ health outcomes, close care gaps, and improve CMS star ratings.

Payers can also gain a precise understanding of the needs of their specific population and respond to areas of high utilization or other distinct challenges.

The APC model uses informatics and population health data to understand where health interventions are needed most.

This data can be used to design outreach: for example, by engaging patients who are overdue for screenings or at risk of developing a chronic condition. This more personalized member experience helps payers to attract and retain MA members.

APC helps MA plans
achieve higher CMS
star ratings

The Centers for Medicare and Medicaid Services (CMS) created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare care options more easily. This metric is intended to measure the quality of health and drug services offered by health plans.

CMS stars rate quality of care from 1 to 5 stars

The key to achieving a high CMS star rating is providing a great member experience, which helps attract new enrollees to MA plans, expand market share, and increase revenue. Here are some of the areas that impact how CMS rates the member experience:

  • Ease of access to care
  • High quality of care
  • Effective care coordination
  • Low rate of complaints

How APC improves the member experience

By investing in a primary care solution, payers gain greater control over care delivery and the member experience. The APC model is designed to enhance every MA patient’s experience by providing:

Longer appointments

The APC model makes time for patients to be fully heard and helps them build trust with their provider. Once trust is earned, patients will feel comfortable enough to open up and talk about all aspects of their health — physical, psychological, and social.

Longer appointments are possible because APC is a value-based model of care. This means that payers, providers, and members all have the same goal: better patient experiences and health outcomes.

Empathetic listening

Listening is at the heart of the APC model — it goes beyond prescriptive medicine by establishing an authentic patient-provider connection and leads to an understanding of a person’s whole health.

Care teams don’t treat patients as a set of symptoms but as individuals who experience unique barriers to better health. Through empathetic listening, care teams can tailor care plans to fit the individual.

When patients feel heard, they also become more invested in their health, which is an important step towards reaching better health outcomes.

Professional health coaches

Every patient’s care plan includes integrated health and lifestyle coaching from a trained professional. These health coaches are trained in the transtheoretical model of change and are embedded in care teams so that patients have easy access to the support they need.

The goal of health coaching is to unlock behavior change — identifying where each patient is in their health journey and helping them move forward. Health coaches empower patients to engage with their health and improve their long-term health outcomes, which contributes to a lower total cost of care for payers.

Customized care and qualified providers

In the APC model, care teams can be fully equipped to meet the specific needs of MA patients. Care teams also have the time and resources to create individual care plans to help MA patients manage complex health issues and chronic conditions.

This approach to care allows payers to earn a higher CMS star rating while improving health outcomes, member experience, and member retention.

APC benefits payers and their members

The complex challenges of limited access to primary care, overreliance on specialty care, and lack of effective care coordination for chronic conditions perpetuate health issues for MA populations. But payers who invest in care delivery through the APC model can create a care experience that is tailored to meet the needs of MA patients. The result is a better experience for members and a competitive advantage for payers.

To learn how Vera Whole Health can help you invest in care delivery,
contact us today.

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