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.
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.
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.
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.
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.