Health system C-suites have mixed feelings about Medicare Advantage plans. Many are frustrated with the high denial rates and low coverage; some have even cut ties with MA plans.
But others see a disruptive force that could have a positive impact on healthcare, if executed correctly.
"I think Medicare Advantage has enormous potential, but that it's currently largely unrealized," Greg Poulsen, senior vice president and chief policy officer at Intermountain, on an episode of the "Becker's Healthcare Podcast." "The reason that it's not been utilized as effectively as it could be, or should be, is that although the federal government CMS pays Medicare Advantage plans on a per capita basis, that's not the way the plans by and large pay their providers. What we have is plans being paid per member per month turning around and paying provider organizations and individual providers on a fee-for-service basis, and undercutting…the correct incentives."
Because providers are paid on a fee-for-service basis, they aren't seeing benefits from improved performance or being incentivized to keep people healthy by avoiding expensive downstream care.
"I would love to see all of our health and Medicare Advantage plans do the kinds of things that would help them to put correct incentives to the providers and the members, the beneficiaries that are participating, to help them work together as teams to help people live healthier," said Mr. Poulsen.
CMS's stated goal is to transition all eligible Medicare fee-for-service and Medicaid patients to plans with a value-based component and zeroing in on the total cost of care. Ryan Nicholas, MD, chief quality officer at Mercy Medical Group in Folsom, Calif., part of CommonSpirit Health, is leaning into strategies supporting Medicare Advantage beneficiaries.
"This represents the greatest market disruption on the near horizon," he said. "This has prompted Mercy Medical Group to move rapidly into value-based care with focus on total cost of care and network integrity."
Mercy Medical Group saw its Medicare Advantage population grow 24% last year and projects another 28% growth in the next 12 months.
"Expanding ambulatory services and improving access for primary care services to reduce unnecessary ED utilization and shorten length of stay is our top priority," Dr. Nichols said.