In the News: Sept 19–26

Medicare Advantage Plans Slow to Adopt Benefits

A recent Modern Healthcare article discusses the adoption pace of Medicare Advantage (MA) supplemental benefits. Despite the federal government broadening the scope of covered benefits, leading MA health plans have been slow to implement benefits that address social determinants of health. In April 2019, Centers for Medicare & Medicaid Services (CMS) released new policies for MA plans that expand coverage for meal delivery, transportation and home cleaning services to support patient management of chronic conditions. However, guidance on how to best adopt and sustainably finance these supplemental benefits was not included in the expansion of benefits directives.

The Urban Institute and the Robert Wood Johnson Foundation conducted interviews and found that the 5 leading MA plans had added few new benefits that address social needs for the 2019 plan year. Explanations for the slow adoption of supplemental benefits include a lack of experience in providing services for social determinants of health as well as financial challenges. On average, the rebates MA plans received were $107 per member per month in 2019, but significant variation by state exists. For example, MA plans in Florida received $159 per member per month in 2015; while in the same year, rebates in North Dakota were $2.

Migration of beneficiaries into MA plans is accelerating in many markets nationwide. It is estimated that since 2010, MA has grown by 71% and covers roughly one-third of all Medicare beneficiaries. To learn more about how health systems can develop an MA strategy that meets the needs of their unique market, please review the Sg2 report Medicare Advantage: Too Big to Ignore.

New Payment Model May Shift Focus

A recent Modern Healthcare article on skilled nursing facilities (SNF) discusses CMS’s decision to replace the existing resource-utilization group framework with the Patient Driven Payment Model (PDPM), similar to bundled payments. The transition to PDPM will begin on October 1, but CMS expects this change to be budget neutral.

The article highlights potential benefits that health systems may experience from this change, such as a lighter administrative burden and revenue increases. However, health systems may need to shift their focus to avoid potential pitfalls. The new payment model no longer bases pay on the volume of therapy services but uses a methodology similar to bundled payments. Therefore, therapy volumes and revenue opportunities are expected to drop significantly.

With already slim margins for SNFs and an ongoing nursing shortage, health systems must prepare for this shift. For key recommendations on how to move forward in the post-acute care environment, please read the Sg2 post Sg2 Strategic Countdown: Restructuring Post-Acute Care.

Partnership Improves Quality and Patient Experience

A recent Healthcare IT News article highlights the partnership between Ochsner Health System and Rush Health System that utilizes virtual health to increase clinical integration between the two systems. The goal of the partnership is to increase clinical collaboration and leverage patient-centered technology to expand access to services in the region.

In 2018, Rush implemented Ochsner’s telestroke program across its 7 hospitals, which allows Rush clinicians to consult with Ochsner’s vascular neurologists. According to the article, the telestroke partnership has reduced the number of patients who need to be transferred to stroke centers from more than 90% to just 30%. Through the extension of the current partnership, Ochsner will implement Epic, giving Rush access to Ochsner’s billing practices and support services to deliver a more seamless experience for patients and providers.

Strategic partnerships create an opportunity to provide clinical and operational benefits for the organizations, community and patients. However, a more advanced organizational structure will be needed as systems continue to seek ways to manage their value-based efforts. To learn more about successful organizational structures with dedicated resources, leadership and governance to help optimize the necessary competencies of value-based care initiatives, read Sg2’s report Organizational Structures to Advance Value-Based Care.

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