The Medicare Advantage (MA) market is at a tipping point, with more than half of all seniors enrolled in an MA plan for their healthcare. Utilization of services is skyrocketing and the Centers for Medicare and Medicaid Services (CMS) has increased pressure to deliver supplemental benefits in a high-quality, low-cost and reportable manner.
As enrollment continues to grow, how health plans are paid — and how much —will be central to the debate over the efficiency and sustainability of Medicare spending.
Focus: Transitions of Care
In response to a challenging landscape, MA plans are focused on improving value, boosting quality and optimizing costs. And they’re finding the best time to get involved is during the transitions of care process, one the most complex and vulnerable times in a health journey.
Research indicates that poor transitions can impact patient safety and health outcomes. For example, an estimated 60% of medication errors occur during transitions of care, and lead to avoidable hospitalizations and prolonged hospital stays.
The stakes are high for the one in four hospitalized Medicare beneficiaries who make the complicated transition to a skilled nursing facility (SNF) for post-acute care. Nearly 25% of those patients are readmitted to the hospital, and just over half return to the community within 100 days post-discharge.
Health plans have a critical role to play in ensuring comprehensive transitions for members. Central to executing is:
- Improving visibility when members are in the hospital.
- Activating collaborative discharge planning that combines knowledge from providers and health plans to best support members.
- Arranging comprehensive transitions of care that include both medical and non-medical services that are aligned with everyone’s goals: fewer ER visits, reduced hospital readmissions, and optimized post-acute care (PAC) length of stay.
- Mastering a traditionally error-prone medication reconciliation process.
- Scheduling other preventative services to fill open care gaps in an integrated care plan for members.
We’ve seen that to make this work, you need deep partnerships with local providers, both to engage members as early in their care journey as possible and to match them with the most appropriate providers based on their needs.
Health plan navigators or care managers may have to arrange multiple services for members, like home infusion therapy, along with home health and meal delivery. Pulling that together in one experience is hugely beneficial, not only for efficiency, but to make sure that no care gaps exist, or if gaps do exist, they can be closed quickly.
But many plans lack the infrastructure and resources to help providers successfully participate in this type of arrangement.
Creating Value at Transitions and Beyond
Health plans will benefit from aligning providers and vendors as strategic partners that are measured against both member- and population-centric scoreboards. When done properly, the outcomes can be powerful:
- Timely initiation of post-acute care services through better management of contracted partners.
- Improved outcomes at a lower unit cost that eliminates duplication or delays due to poor care coordination.
- Happier members (who renew) because they see and feel the positive effects of investments in a better care coordination experience, have an increased knowledge of their non-medical benefits, and see how those benefits are useful in critical moments like hospital transitions.
Being successful here will ultimately show up in improved transitions of care Star Ratings, improved total cost of care as measured by top-level KPIs like ER visits, hospital admissions, average post-acute care length of stay, member satisfaction scores, and utilization rates of non-medical benefits.
Meeting Member’s Changing Needs
For health plans, winning and keeping members isn’t just about keeping pace with the latest benefit offerings. It’s about delivering personalized service to meet members’ changing needs. Some are further along than others in this journey.
We expect the winners will plan for growth that’s driven more by member retention than purely new-member acquisition, and, as a result, an increased need to deliver personalized and high-quality care experiences. The challenge is doing this at scale without creating an increasingly fragmented experience. Not only does this have the potential to delight members, but we’ve found that the right digital tools help organizations scale without adding more people to manage an increased workload.
In a challenging market where organizations have to demonstrate a compelling path forward, modernizing the approach to transitions of care is an opportunity-rich place to start.
About Ashish V. Shah
Ashish V. Shah founded Dina in 2015 and leads the team on its mission to make in-home care accessible, reliable and transparent. Dina provides digital network management and coordination solutions to help health plans and providers improve access to in-home care, long-term services and supports, and supplemental benefits.
