Medicare Advantage plans have faced obstacles providing customized care for complex and seriously ill patients, but a recent report found it was primed to provide innovative ways to improve care for the seriously ill.
A report published by the Margolis Center for Health Policy at Duke University found “Medicare Advantage’s financing structure and increased flexibility following recent statutory and regulatory changes make it a fertile environment for testing new payment and care delivery innovations for patients with serious and advanced illness.”
There is no precise definition for a serious illness, it can be a range of characteristics including:
- one or more serious chronic illnesses;
- complex care needs, including high utilization andassociated costs;
- functional limitation or disabilities; and
- for patients with advanced illness, health is unlikely to improve but face variable rates of continued decline.
Seriously ill patients and those with complex medical needs offer the greatest possible return on MA investment because they typically incur higher costs; when the cost of an MA plan enrollee’s capitation exceeds the cost of care the plan is allowed to keep those savings. Plans delivering “high quality care,” as determined by the Centers for Medicare & Medicaid Services’ (CMS) Star Ratings program, are also eligible for bonus payments.
For these reasons, Medicare Advantage plans are creating care models aimed at seriously ill members that will also maximize incentives and help move another sector toward a value-based system. The report however, cautions “there is very limited publicly available evidence about value initiatives launched by Medicare Advantage plans, including broader payment, delivery, and benefit reforms.”
To demonstrate MA’s potential for innovative care for the seriously ill, the researchers examined three models developed by firms that contract with MA health plans–Aspire Health, Landmark Health, and Turn-Key Health.
It was discovered that the three models share some common features:
- All three analyze the claims data they receive from plans in order to identify patients that meet the eligibility requirements for their services.
- Members of the care team conduct their own health and functional assessments of patients when they enter their cohort and update them regularly while patients are in their care.
- All of them deliver care to patients in their home or residence in facility settings.
- All of them provide round-the-clock accessibility to patients, which is critical for quickly addressing patient concerns and needs in order to prevent or divert emergency visits and hospital admissions.
- Providers from all three models conduct advance care planning discussions with patients and their families and caregivers in order to help them consider and plan for decisions that will need to be made as the patients approach the end of life.
- Highlight a degree of flexibility in contracting and payment structure that the organizations have while still making their models work for all parties.
The models implemented by the three third party firms confirms that there are indeed innovative approaches within Medicare Advantage markets currently addressing payment and care delivery for the seriously ill.
There are expansion barriers that MA’s innovative care models also face including rural economics, workforce training, and inflexibility in traditional Medicare. Researchers who published the report also offered three recommendations to promote these care models, click here to read the report.
Check out the Health Leaders’ article, here.
Read the full report here.