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Five Things to Know About Medicare Advantage Plans


Here are five key points about Medicare Advantage plans to answer questions and clear up misinformation for physicians.

Of all the evolutions seen in senior healthcare over the past four decades, few have proved to be more significant than the changes in regulations in the 1970s that provided Medicare beneficiaries the freedom to opt out of traditional Medicare and instead receive healthcare benefits through private health plans. Today more than 14 million American seniors and individuals with disabilities - about 28 percent of the total Medicare population - are enrolled in Medicare Advantage (MA) plans. They depend on these plans to provide high quality care coordination, to greatly reduce their out-of-pocket healthcare costs, and to provide them with a host of important benefits not covered by Medicare, such as preventative care and, in some cases, dental care, vision care, transportation, or even gym memberships.

Caring for these members are physicians in all 50 states who, through an IPA, organized medical group, or on their own, have contracted with MA plans to serve the fastest-growing demographic in America. But many questions and misinformation continues to exist regarding MA plans and the role they play in cooperation with their physician partners in providing affordable, accessible, quality care to members.

It's time to clear that up with five important things to know about Medicare Advantage:

1. Care coordination works. Repeated studies have shown that seniors enrolled in managed care experience fewer hospital admissions and readmissions, fewer emergency room visits, and lower overall medical costs. The key to success in all of these areas is emphasizing primary prevention, early intervention, and effective care coordination throughout the spectrum of care. At-risk seniors can be part of geriatric health-management or disease-management programs and can benefit from a medication-management program that focuses on the correct match between diagnosis and drugs. MA plans help assure the appropriate utilization of services, improve the coordination of care with different providers, and improve clinical outcomes every step of the way. In short: the right care at the right cost at the right time.

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2. MA plans are driven to improve quality. The Five Star Quality Rating System serves as the driver for the quality care provided to the beneficiaries. MA plans are rated on a scale of 1 to 5 based on 53 specific topics that incorporate process measures, outcome measures, and patient experience measures. Some of these measures include how often members got various screening tests, vaccines, and other check-ups that help them stay healthy; how often members with chronic conditions got certain tests and treatments that help them manage their conditions; drug pricing and patient safety; customer service; and overall member satisfaction. MA plans have both a financial and public-perception motivation to excel in each of these areas and improve their star ratings.

3. MA plans are attractive to younger seniors. The first of our nation's 77 million baby boomers has already turned 65. This is the first generation of Americans that has grown up with an understanding of managed care. They are enrolling in MA plans because they like programs that keep them healthy and provide more value through various disease management programs leading to ultimate cost savings. So while MA plans attract older adults with chronic conditions and ongoing needs, the number of "younger seniors" opting for MA plans is actually higher than the overall membership mean.

4. Enrollment happens all year round. The annual Medicare enrollment period of Oct. 15 to Dec. 7 is the only time when most seniors are able to determine what health plan they want for the coming year. But that's not the only time physicians may see new MA patients. A special-election period continues all year long for dual-eligible members and those who qualify for chronic special needs plans. In addition, people age into Medicare all year long - at the rate of one every eight seconds - and these individuals have a seven-month window to make their initial coverage selection. As a result, MA plans provide a year-long opportunity for physicians to build their practice.

5. We're all in this together. Today about 11 percent of our country is age 65 or older. But in about two decades, one in every five Americans will be elderly; and by the midpoint of this century, there will be 1 million Americans over the age of 100. Physicians and MA plans have a shared responsibility to address the ongoing healthcare needs of this population in a sensible, respectful, and affordable way. Working together we can assure a proper utilization of healthcare resources while helping seniors remain active, independent and relevant.

Romilla A. Batra, MD, MBA, is corporate medical director at SCAN Health Plan, one of the nation's largest not-for-profit Medicare Advantage plans. E-mail her here.

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