Medicare Advantage has grown rapidly in recent years, with 32.8 million people (54% of the eligible Medicare population) now enrolled in an MA plan. Health systems are grappling with various challenges within the program, such as excessive prior authorization denial rates and slow payments from insurers, but some organizations have positioned themselves for success.
"MA is a hot topic these days," Kyle Fisher, CFO of Indianapolis-based Community Health Network, told Becker's. "The market in general took off on the East Coast and the West Coast and it’s finally hitting the Midwest."
Community, a 10-hospital system, is in several MA plans and invested in an insurance company with other providers to operate its own MA plans.
"Not only are we participating in it as a provider, but we're also engaged in it directly. We’re getting shared savings out of the plans we're operating, but it is complex and the rules seem to be changing," Mr. Fisher said. "We're trying to take as little downside risk as we can but we understand that value-based care is here. We're successful in value-based care and it will continue to grow, certainly within the state of Indiana."
Community has a dedicated team that is focused on providing quality care and achieving shared savings through its MA plans.
"You've got to have a team with great discipline and good processes in place," he said. "In terms of the metric you're trying to achieve, it really boils down to having a solid team focused on care delivery, particularly around the MA population."
As the MA landscape continues to evolve, health systems' success hinges on their ability to excel in areas such as star ratings and appropriate coding, SCAN Group CEO Sachin Jain, MD, told Becker's. Health systems' biggest opportunity is to enter into full-risk arrangements with health plans, shifting the focus from managing illness to maintaining wellness.
"Success in MA is predicated on whether or not health systems are making the requisite changes," Dr. Jain said. "To be successful in MA, there needs to be an exquisite performance in both stars program as well as appropriate coding. When health systems engage in both, they have the opportunity to perform well."