Workflow Efficiencies for Increased Reliance on Medicare Advantage

Health plan and provider collaboration

For the first time in Medicare’s history, more than half of all eligible people with Medicare, or 30.8 million people in 2023, are enrolled in private Medicare Advantage (MA) plans. According to KFF, MA is already the only option for retiree health coverage for Medicare-age retirees in 12 states.

This additional reliance on MA comes at a time when reimbursement rates still aren’t quite on par with expected usage trends (according to a Kiplinger report), creating strain for both health plans and providers to reach desired outcomes. As the aging baby boomer population increasingly relies on Medicare Advantage plans and membership adoption grows, health plans and providers will need to leverage workflow efficiencies through proactive patient insights to meet their goals of adapting to new risks and improving value-based care.

Challenges for Health Plans and Providers Shifting to Support Medicare Advantage

Health plans and providers face unique challenges in pursuit of value-based care.

Health plans must reckon with insufficient reimbursement rates relative to expected usage trends, the need to reduce costs through controlling medical cost ratios and the consistent need to upkeep Healthcare Effectiveness Data and Information Set (HEDIS®) and CMS Star Ratings as a key lever to maintain financial health.

Concurrently, providers’ bottom line is dependent on their ability to deliver high-quality, low-cost care during a time when health plans are placing more responsibility to execute on that mission.

Both must work together to meet needs and avoid a breakdown in the system or gaps in patient care. Health plans need providers who are also working in value-based care arrangements, and providers need data and tools to execute on these value-based care agreements.

Tools for Greater Patient Engagement

Increased member reliance on Medicare Advantage will put pressure on acute and post-acute organizations to maintain efficient processes, necessitating the use of proactive tools like real-time patient insights to continue providing care during pivotal moments. Clinicians and health plans can leverage several proactive tools for greater patient engagement, including:

  • Real-time patient e-notifications during important care events, enabling scalability with managing PPO and HMO patient populations.
  • Insights into patient status and network utilization across full geographic regions, whether a patient is at a hospital, post-acute facility or presents at the emergency department to allow care team members to intervene before a patient receives treatment, or to schedule follow-up appointments in a timely manner.
  • Systems that allow for shared patient data between providers and health plans.
  • Actionable opportunities to improve transitional care management.
  • Automation drivers for streamlining prior authorizations to improve processes for staff and patients receiving care.
  • Ongoing reporting to capture increased cost savings and quality performance improvements with programs such as CMS Star Ratings and HEDIS.

For proactive tools like these to be effective, disparate healthcare systems must continue to prioritize effective data-sharing between their entities to better understand their shared patients and members.

By addressing these key areas, health plans and providers can better navigate the transition to Medicare Advantage plans, ensuring that they are equipped to meet the evolving needs of the aging population while maintaining efficient and effective care delivery systems for improved patient outcomes. 

To learn more about improving patient engagement and workflow efficiency, contact us.