A New GoHealth Report Examines the Role of Value-Based Care in Medicare Advantage for Seniors

The Medicare Improvement for Patients and Providers Act program supports states and tribes through grants to provide outreach and assistance for helping eligible Medicare beneficiaries.

The Affordable Care Act provides premium tax subsidies and expands the Medicaid program.

The Medicare Access and CHIP Reauthorization Act of 2015 created the Quality Payment Program (QPP) that streamlines quality programs under MIPS and gives bonus payments for participation in eligible alternative payment models (APMs).

Collective intentions were good, yet the healthcare system faced harsh realities. A transition to value-based reimbursement came with growing pains. Both providers and carriers discovered that finding value for all parties would be difficult without practice, coordination, and resources to match.

Today, insurance carriers and providers are embarking on a slow, yet steady, march across the risk-sharing continuum, from traditional fee-for-service (FFS) toward alternative payment models. None are moving as fast as those in Medicare Advantage (MA), which is outpacing Medicaid, Original Medicare, and Commercial segments in the adoption of population-based payments at 17.2% compared to 5.9%, 4.4%, and 2.5%, respectively.

Why is this so? Because Medicare Advantage prioritizes value over volume, and population health over service velocity.

These shared values between Medicare Advantage and Value-Based Care (VBC) make the two perfect partners in healthcare. Both work best when incentives align toward better care and outcomes.

Value-Based Care Prioritizes Cost and Quality

VBC in Medicare Advantage challenges the notion that more is better. Instead, it asserts that better is redefining what value means to each stakeholder and replacing volume and price with cost and quality.

The result? Aligned outcomes.

A typical senior’s healthcare journey, from plan selection to care delivery and benefits navigation, involves points of friction that increase cost and chip away at quality. Although care coordination is no easy task, such high levels of fragmentation are preventable through collaboration.

Take it from Paul Hain, M.D., Chief Medical Officer at GoHealth:

“Medicare beneficiaries, and those aging into it, are tasked with navigating their own health insurance, and too many do it on their own, landing them in either financial debt or worse, poorer health due to misused care. The patient journey is fragmented, all the way from enrolling in an insurance plan to navigating the health system to understanding payments.”

Care Delivery, Reimagined

This all happens at a time in which the COVID-19 pandemic is driving virtual care preferences, with nearly half (49%) of current Medicare beneficiaries being open to the idea. Another 20% have already seen a doctor virtually.

Learn more in GoHealth’s Biannual Medicare 2020 report.

Recent regulations and legislation could also help clear remaining barriers that stand in the way of VBC realizing its true potential. Much-needed relaxation of HIPAA telehealth regulations led to telehealth’s rapid uptake during the pandemic, enabling physicians to provide virtual care to homebound patients. Requirements for patient access and provider directory APIs go into effect this July, paving the way toward a more unified data infrastructure.

The MA Advantage

In a recently published AJMC study, increasing patient contact with doctors cut Medicare Advantage costs by 28% and led to 50% fewer hospital admissions for seniors. How, you ask? Physicians spent an average of 200-250 minutes per year with their patients, making the under 20-minute benchmark that most of us receive pale in comparison.

Medicare Advantage is the perfect place for VBC to thrive, especially given the shared focus of value over volume and population health over service velocity. Both work best when goals align toward better care and outcomes.

Check out the value that a Medicare Advantage plan brought this GoHealth Medicare member, Eduardo T.:

I was diagnosed with prostate cancer, and Merrill helped me find a plan that wouldn’t charge me a penny for a series of chemotherapy injections that cost $5,000 each. He explained everything to me with such care and calmness that many don’t take the time to genuinely do. Because of his efforts, I won’t have to pay a single penny for my treatments and doctor visits. On top of that, I now have $50/month that I use at my local grocery store for healthy foods, and $100/month for over-the-counter items like ibuprofen and cold medicine.

It takes team effort to engage members in supplemental benefits, promote efficient utilization, and support aging-in-place. By manifesting the spirit of aligned goals, together we can build a better future for seniors and improve access to healthcare in America.

The transition from FFS to VBC in Medicare Advantage draws a sturdy bridge between parties, aligning goals around personalized care that can improve quality while reducing costs. GoHealth is proud to play a role in helping seniors achieve this mission and secure better outcomes.

Download the full report, “State of Value-Based Care in Medicare Advantage, 2021 Outlook"

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