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CEO Blog: The Medicare "Advantage"

By Orion Bell   |       |   10/31/2019

The open enrollment for Medicare plans began on October 15 and it got me thinking about a recent incident with my father.

A few weeks ago, I was home visiting my parents. While we were sitting at the kitchen table, my dad got a phone call.  It was the nurse from his insurance company.

At least that’s what the prerecorded voice said. What followed was a scripted “conversation” with the automated system, a customer survey about his recent medical appointment. The system was intended to simulate questions from the nurse. But the technology wasn’t working quite as intended.  The computer didn’t hear his responses, so it switched over to multiple choice, “press one for yes; press two for no…”  Dad was a good sport about it, tapping the keys on his phone to reply.  At the end of the “interview” the computerized voice encouraged him to stop smoking and get more exercise. Dad has never smoked. He still swims regularly. His most recent trip to urgent care was the result of falling off his bicycle. This automated call illustrates what works, and what doesn’t, in health care.

Medicare is the health insurance program for most Americans age 65 and older. Established in 1966, Medicare enrollment exceeded 58 million people in 2017. Enrollment is projected to increase by 1.5 million people per year for the next decade, as the Baby Boom generation ages. Medicaid provides health care coverage for low-income Americans. The “dual eligible” population – those who qualify for Medicare (due to age) and Medicaid (due to household income) includes the poorest and sickest people in the country.  

According to the Centers for Medicare & Medicaid Services, Medicare spending represented 20 percent of all health care expenditures nationally in 2017. When Medicaid is factored in, older adults represent 15 percent of the population, but account for 34 percent of all health care expenditures. As health care costs increase, and the number of older adults rises, there is a growing emphasis on addressing the “triple aim” in health care: promoting population health, improving quality of care, and lowering the costs of treatment.

Medicare and Medicaid spend a LOT of money on health care. Combined spending on the two programs exceeded $1.2 trillion in 2017, more that spending by all private health insurance plans combined. Chronic health conditions drive much of overall health care costs. Prescription drugs prices have increased much faster than the overall rate of inflation. Thirty million Americans live with diabetes, while the price of insulin tripled over the past decade.  Successful treatment of chronic health conditions depends on many factors beyond medical treatments: diet, exercise, adherence to plans of care.  There is a lot of attention these days on “social determinants of health” but the idea is nothing new.  Remember “an apple a day keeps the doctor away” ? Or “an ounce of prevention is worth a pound of cure”?

One of the challenges of America’s “market-based” health care system (It’s not really “market-based”, but that’s a different blog post,) is that health care payments are still primarily focused on treatments and procedures, not health or wellness.  Most productivity and profit measures for hospitals and physicians are driven by payments for the service provided, whether it’s surgery, medication or therapy. There is little incentive for an administrator to reduce traffic in the hospital.  Better health, ironically, can be bad for business.

CMS is seeking to harness the buying power of Medicare and Medicaid to control costs, reward desired incomes and improve health. One of the initiatives undertaken by Medicare is the creation of accountable care organizations (ACOs), which bundle health services for a target population to reward better health and better coordination of care by sharing savings from reduced medical expenditures with the health systems. Beginning in 2020, Medicare Advantage Plans may begin to offer coverage for non-medical services that help address chronic health conditions or activities of daily living, such as meals or attendant care.  And some plans have long included additional features that are designed to promote better health, including fitness plans or gym memberships intended to promote better health and healthy habits.

The triple aim includes a focus on quality of care provided. Checklists and standardized procedures help address quality and consistency of care.  Electronic medical records provide accurate and up-to-date information about health of the patient, including information about the other treatments that person is receiving.  Better data collection and analysis leads to development of improved interview tools and electronic prompts for practitioners. That computer screen your doctor looks at while she is talking to you? It may be helping guide her questions or recommendations for your care. Standardized assessment tools also make it possible for paraprofessional staff or community health workers to gather information that helps refer people to care when they need it.

Another strategy is to focus on the consumer directly. Asking for feedback, coaching and encouraging the individual to commit to a plan of care, setting personal goals for improvement and being a better-informed consumer of care. Research suggests that 80 percent of health outcomes are a result of those social determinants of health. An engaged, informed consumer is key to better health outcomes, and lower costs.  The insurer, armed with claims data and contact info on their covered lives, is in a position to promote this kind of engagement.

But… a checklist in the hands of a medical professional, or a survey administered by a community health worker… is not a computerized “nurse.” Instead of increasing his engagement with his doctor, my father’s health care “interview” became just one of many robocalls my father received that day. If anything, it reinforced the notion of the insurer as distant and uninterested. The robocall may have been less expensive to complete. But, did it accomplish anything?

Medicare open enrollment began on October 15 and runs through December 7. This is an opportunity to select coverage through traditional Medicare or Medicare Advantage programs.  Medicare Advantage plans offer multiple options for coverages premiums and out-of-pocket costs.  Consumers can review a variety of plans and select one that best fits their health care and financial needs.  And, there is free, unbiased assistance available to help navigate the choices that are available. Learn more at www.esop-cleveland.org

Learn more about:

Medicare coverage comparisons: https://www.mymedicarematters.org/coverage/compare/

CMS data on Medicare: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics/2017/2017_Enrollment.html#Total%20(Fee-For-Service%20and%20Managed%20Care)%20Medicare%20Enrollment

National Health Expenditure Data: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html

Accountable Care Organizations: https://innovation.cms.gov/initiatives/aco/

AARP Medicare data (2009): https://assets.aarp.org/rgcenter/health/fs149_medicare.pdf