5 Challenges Payers Must Solve to Serve Medicare Advantage Populations Well

More healthcare services and controlled costs. That’s the premise of Medicare Advantage (MA) plans. Who — retiree or otherwise — wouldn’t want that? The attraction is undeniable, but so are the limits MA patients encounter, starting at the primary care level.

MA patients use the same, broken volume-based healthcare system as everyone else. When primary care providers are merely gatekeepers for referrals to specialists, costs go up while patient health declines.  

Payers who want to attract and retain more MA members must solve five key challenges if they want to build they want to improve member acquisition and retention while also achieving adequate CMS Stars ratings.

Limited access to and time spent with primary care providers 

MA members struggle with access to primary care providers. Oftentimes waits for an office visit can extend six months or more. When their appointment finally arrives, the visit lasts an average of 8 minutes, clearly not enough time to discuss complex or chronic health concerns or needs. In those settings, patients seldom actually receive care, instead referring patients to specialists, adding additional costs.

Over reliance on specialty care

Frequent specialist referrals are standard practice in fee-for-service healthcare settings. This practice causes problems beyond the high costs it incurs. Speciality care in traditional fee-for-service systems takes place in isolation without primary care provider involvement or, many times, awareness, leading to reduced outcomes and a disjointed member experience.

Ineffective or nonexistent care coordination 

Patients must navigate a disjointed traditional care system on their own. Next steps following specialty care may not be part of the equation. Limited access to primary care providers who would provide guidance further complicates the matter.

Provider networks not aligned to serve MA members

Under typical healthcare plans, a primary provider's panel may consist of patients from an unlimited number of payer organizations, each with its own patient objectives. The needs of an aging population evident in MA members receive no special regard, resulting in providers treating just symptoms, not conditions – age-related or otherwise. 

Quality ratings and seeing more Stars

Organizations who wish to market their MA plans year-round face a unique challenge: receiving a high enough CMS Stars rating. Patient satisfaction, a key metric in both HEDIS quality and Stars ratings, is merely a byproduct of care services in traditional healthcare settings. 

A path for payers, providers, and plan members

Payers must address these 5 challenges to find ways to attract and retain more Medicare Advantage members and ultimately solidify their position in a stand out in a highly competitive market. 

In our next post, we’ll take a deep dive into how an advanced primary care model solves these challenges and positions payers for growth in the Medicare Advantage space. Check back later this week for more. 

Learn how Vera is championing the healthcare revolution through APC.