Even before the COVID-19 pandemic took hold in our communities earlier this year, change was already afoot in the American health care system as payers and providers increasingly move to demonstrate and reward value – better health, experience of care and reduced costs – rather than the volume of services delivered.
Population health management strategies deployed by Medicare Advantage plans, the managed care option in Medicare where over one-third of beneficiaries receive coverage today, have maximized fixed per-member, per-month payment for each beneficiary’s care to deliver such value.
According to independent research commissioned by Better Medicare Alliance, these strategies have resulted in a 94 percent satisfaction rating among beneficiaries, nearly $1,600 in annual consumer savings, access to an array of supplemental benefits and improved health outcomes and reduced hospitalizations.
As coronavirus continues to impact the entire health care ecosystem, we see pre-COVID gains in value-based care that must be preserved, new trends that are rapidly accelerated, and demands on our health care system that should be addressed. The Medicare Advantage model offers opportunities to do exactly this, individually and at scale. In fact, a new report from Better Medicare Alliance provides numerous examples of how Ally organizations are innovating to meet seniors’ needs in new ways – even now.
As we prepare to move beyond the initial surge of coronavirus with an eye toward long-term solutions to protect vulnerable seniors and enhance their wellbeing, here are some of the factors to consider:
Holding and Enhancing Pre-COVID Gains
1. Analytics Supporting Individualized Needs and Preference-based Care Supports: The 65-year cut point is just that: a cut point. If we look at five-year age bands as populations, the 65-70 group on average looks very different from the 85-90 group in terms of co-morbidity and frailty. Furthermore, individual health and wellbeing profiles vary widely despite chronological age, as do consumer goals and preferences, including aging at home as the preferred environment. Advanced analytics are creating population level insights and individual profiles to support tailored care and life planning.
2. Integrated Medical-Behavioral Care: When behavioral health accompanies a medical condition, especially chronic conditions such as diabetes, cardiac disease, kidney disease, and COPD, total costs are at least two to three times higher. This is compounded when underlying behavioral health issues go undetected or undertreated. Medicare Advantage enrollees benefit from care teams who work together to treat the whole person; offering coordinated care with an emphasis on primary care that can be brought to bear in behavioral health needs arise.
3. Continuity of Care: Significant reductions in avoidable readmissions, improved health and experience of care outcomes and expanded opportunities to enjoy everyday life for seniors, have been accomplished across numerous geographies. This has largely been the result of better discharge planning, care supports, medication reconciliation, and systematic follow-up. Transition of Care programs further support seniors as they progress from acute to post-acute to home-based service supports to full recovery and maintenance. Primary care and annual wellness visits provide an avenue to assess for relapses or emerging health concerns.
4. Addressing Social and Environmental Influences: Substantial investments in Social Determinants of Health (SDoH) initiatives e.g. food insecurity, transportation, housing and social isolation have been made over the last several years not only because it’s the right thing to do but because research supports the impact of these social issues on health and cost indicators, and reduction in cost when SDoH issues are addressed. Coordinating efforts across Community-based Organizations (CBOs) has been critical to this advancement as, like medical and behavioral issues, SDoHs come in clusters – often with the common denominator of financial instability. A recent independent study from the actuarial firm Milliman shows how Medicare Advantage plans leverage supplemental benefits to address SDoH – with nearly half of plans offering meal benefits for those with chronic conditions and 44 percent offering transportation between appointments.
Trends Further Accelerated by COVID:
1. Digital Triage, Coaching and Navigation: For seniors needing maintenance support for chronic condition prevention or management, technology-supported workflows assist in getting consumers to the best intervention for their fluid place in the health continuum at any given time. As social support issues are escalating, seniors may not only feel pressure on their own resources but also feel pressure to help struggling children or grandchildren requiring further support for seniors to prioritize their health needs.
2. Engagement in New Times: As social distancing becomes a new norm whether permanent or periodic, seniors may experience social isolation, fear, and loss of purpose. Thus far, creativity has at least partially eclipsed restrictions with virtual video visits, birthday parades, technology-enabled recreation, and asynchronous voice and image transmission. Better Medicare Alliance recently reported on how its Ally organizations are working to stem the effects of social isolation, with primary care providers like ChenMed calling patients at risk at least once a week. Likewise, Humana has made over 500,000 proactive calls to beneficiaries during this time.
3. Shift to Home-based Services: House calls and technology including telehealth for routine and follow-up care, remote patient monitoring of blood pressure, heart rate and rhythms, and weight have grown exponentially in adoption. Home test kits for lab studies have been distributed where possible and access to wellness activities and health coaching have greatly expanded. Today, nearly 90 percent of Medicare Advantage plans provide supplemental and health promotion benefits.
4. Expanded Use of Well-trained High-touch and High-tech Care Team Members: With primary care provider and geriatrician shortages growing, care extenders skilled at assessing and managing special needs of the senior population, including falls prevention, polypharmacy and avoidable or manageable declines in cognitive status have been mobilized. Further, the use of tools including artificial intelligence, remote monitoring devices, smart mattresses, GPS trackers, and voice alerts from two-way personal speakers are beginning to mimic 24-hour surveillance by a care team member.
While there are many lessons still to be learned from the recent changes in service delivery and consumer behavior, there are positive developments all around us that point to a brighter health care future for seniors and those with disabilities – even amid the deep challenges posed by COVID-19 – with Medicare Advantage leading the way.
As health care continues to evolve, new concepts show promise of staying power. Using telehealth in behavioral health settings, for example, has been of increasing interest because of costly numbers of undetected and undertreated individuals, provider shortages, stigma in seeking care, and the growing numbers of individuals experiencing symptoms of anxiety, depression, and emotional trauma resulting from the coronavirus pandemic. Alignment of need and demand with regulatory requirements and payment models, and removing consumer barriers to adoption such as cost, access, and training are key takeaways from which to expand.
In addition to telehealth, the shift to better supporting seniors in their home environments with individualized, comprehensive care through integrated medical, behavioral, and social services will continue to be a top priority. After all, home is the environment that most seniors and their children prefer. The expanded shift to home will entail home care team visits and use of technology to promote health and monitor vital signs, symptoms, and activity could provide early warning signals of trouble to prevent avoidable complications, ER visits, and hospitalizations. Supporting seniors and providing every possible convenience in the home will require balance. Maximal life enjoyment is the endgame across the full continuum of health. Perhaps we all now better appreciate the value of getting outside to enjoy everyday activities, such as a trip to the store, exercise class, or a family member’s house.
No doubt the next phase of coronavirus recovery will be wrought with challenges as the economy and individual healthcare businesses suffer a decline and then stabilize, perhaps in a new form. Certainly, for years to come, the learnings from this period must continue to spawn further innovation on behalf of the growing senior population who desire quality, safety, convenience, and affordability as they live life to their fullest potential.
Rose Maljanian is the Chairman and CEO of HealthCAWS Inc. and is the Chairman Emeritus of the Population Health Alliance.