Medicare Population

Listen to Elena McFann, President, Medicare & Government Business Division, and Omar Latif, MD, Vice President, Medicare Clinical Operations, discuss the unique needs of the Medicare population and how we're partnering with care providers to help their patients achieve real whole health.

Dr. Omar Latif: The Medicare population has unique needs. The program itself has evolved, and that has impacted our approach.

Elena McFann: Medicare has changed so much through the years, only compounded by the acceleration of that pace of change. We have unprecedented stress on the delivery system from the pandemic. We have the proliferation of care models that are not centered around an inpatient stay. Medicare eligibles have become increasingly sophisticated around what they need and want from a plan. And then finally, CMS has recognized that patient experience is a domain to measure and incentivize performance.

So, this increases the importance of health equity and social drivers of health as an important lever to achieve positive outcomes. One of the biggest differences is related to payment for Medicare and the move to value-based care.

Omar Latif: Yes, people often focus on the payment aspect of value-based care, and for good reason. It's important to drive higher quality of care and drive affordability. Our data shows a stark difference in various health measures for Medicare patients in value-based programs versus those who are not in a value-based program, which is not only the goal of every clinician, but also helps their bottom line, and results in better star ratings.

Elena McFann: More than ever before, there is an intense focus on the patient experience, and provider-led actions are an influencer of success in this important domain.

Omar Latif: That's precisely why our value-based care strategy seeks to reward not just clinical knowledge, but those care providers that develop industry-leading expertise in other aspects of healthcare. It's about having access. It's about a better overall encounter with the healthcare system before, during, and after the visit. We have collaborative efforts underway to equip care providers with the tools to make improvements, enabling clinical data and insights, trainings, post-visit surveys. Plus, we've aligned our case managers and pharmacists with them.

All this is coupled with benefit designs that enable patients, and their care providers, to address whole health. For example, simplified supplemental benefits to help those who have a Medicare plan get over-the-counter meds and even groceries.

Elena McFann: We are focused on helping care providers create a special connection with their patients who have a health plan with us. But given the health complexities that the Medicare population in particular faces, that can be easier said than done.

Omar Latif: Understanding the big picture about every person and integrating all aspects of their health, whether it's physical, social, behavioral, pharmacy, it's all critical.

Elena McFann: For many Americans, especially seniors, pharmacy is one of the most common touchpoints in the healthcare system. More than half of adults over 65 report taking four or more prescription medications. If we deliver those medications directly to their homes, we can help increase medication adherence and satisfaction and improve clinical outcomes. Better outcomes help care providers reach their value-based targets.

Omar Latif: Healthcare presents a great many challenges, but we are committed to advancing health together with our care provider partners.

Medicare: Making the Case for Value-Based Care

Contributing experts: Elena McFann and Omar Latif, MD

The Medicare program, established nearly 60 years ago, provides healthcare coverage to tens of millions of Americans age 65 and older, and younger people with qualifying health conditions, who might not otherwise be able to afford it. Medicare has long helped provide financial security to people while also benefiting society by stabilizing the economic impact risk this population poses. While the program has seen changes and challenges over time, today it is more important than ever because an estimated 10,000 Americans become eligible for Medicare every day.¹ Already accounting for 20% of national health expenditures² — a statistic expected to grow disproportionately — Medicare is a case study for why moving from fee-for-service reimbursement to value-based care is imperative.

Our Approach: Focusing on the Consumer Experience

Our affiliates' Medicare Advantage (MA) health plans serve nearly 1.9 million Americans in 25 states and Puerto Rico.³ Across all markets, we are working with their care provider partners to create aligned financial incentives that help deliver patient-centered, quality care through an approach that's hyper-focused on the consumer experience.

These care provider partnerships aim to drive positive behaviors among the Medicare population, such as taking advantage of value-add services like home visits, preventive care at no extra cost, and cancer screenings.

Because of these care provider partner relationships, we have nurses aligned and working in unison with PCPs, with cobranded outreach done on behalf of the care provider. This enables our teams to encourage — and actually schedule — annual PCP appointments as well as home visits. Data can then be fed back to the consumer's PCP so that their care provider can work with them to manage their health.

Such higher degrees of engagement with primary care lead to a better experience, as measured by Consumer Assessment of Healthcare Providers & Systems (CAHPS) scores, as well as improved clinical outcomes such as preventive care utilization, medication adherence, and post-hospital follow-up. Importantly, this engagement also creates trust to help consumers take advantage of benefits like home delivery of medications — consumers who use such services have higher retention and positive clinical outcomes.

Our Progress

When it comes to health measures, our data shows a stark difference for consumers who are in value-based programs versus those who are not. Results improve even more when care providers take on downside risk. For example, among our affiliated health plans' Medicare population:⁴

Annual Planned Visits %: Difference Between Value-Based Care and Non-Value-Based Care: 12.5%, Difference Between Downside-Risk Value-Based Care and Non-Value-Based Care: 15.5%

Colorectal Cancer Screenings %: Difference Between Value-Based Care and Non-Value-Based Care: 4.6%, Difference Between Downside-Risk Value-Based Care and Non-Value-Based Care: 4.0%

Controlling Blood Pressure %: Difference Between Value-Based Care and Non-Value-Based Care: 24.3%, Difference Between Downside-Risk Value-Based Care and Non-Value-Based Care: 26.8%

Diabetes Blood Sugar Control %: Difference Between Value-Based Care and Non-Value-Based Care: 21.7%, Difference Between Downside-Risk Value-Based Care and Non-Value-Based Care: 28.8%

Plan All-Cause Readmissions %: Difference Between Value-Based Care and Non-Value-Based Care: -0.6%, Difference Between Downside-Risk Value-Based Care and Non-Value-Based Care: -1.2%

Spotlight: Supporting Primary Care

PCPs are the heartbeat of our healthcare system, especially for Medicare beneficiaries, many of whom have complex, chronic conditions. It's why over the past three years, Elevance Health has emphasized partnering with PCPs and investing in new and innovative primary care models to support all consumers, regardless of geography or health status. Those primary care models include:

Advanced primary care clinics like CareMax, CenterWell, and our own — CareMore. Such clinics have smaller patient panels, focus on comprehensive whole-person care, and adopt a "whatever-it-takes" approach to creating exceptional patient experiences and health outcomes.
Aggregator models like Agilon, Aledade, Privia, and VillageMD. These organizations align independent PCP practices, providing them with analytics, technical support, and other capabilities needed to deliver superior care and transition to value-based care.

While overall hospitals and healthcare systems have developed the infrastructure needed for transitioning from fee-for-service to value-based care, independent care providers often have a hard time staying truly independent. They can benefit most from the services aggregators provide.

Our aggregator partners enable independent PCPs to better succeed in risk-based arrangements with resources, including subject matter experts, actionable data, and practice management support.

Forward Together

Medicare Advantage consumers are often managing chronic and age-related conditions, and, like all of us, they deserve closely coordinated, accessible, and high-quality care. Care providers have both an opportunity and a challenge to support a path to maintaining and managing wellness.

Our affiliated plans have been working to ensure that care providers' payment arrangements drive the type of care that these consumers deserve. That means supporting a primary care office as the nexus for health, sharing timely information with doctors and hospitals in support of well-coordinated, evidence-based care, and ultimately, holding care providers and ourselves accountable for ensuring consumers receive the right quality care, at the right time, in the right place, with the right experience.

When incentives are aligned to the values that Medicare consumers place on care, access, and experience, everybody wins — payers, care providers, and, most importantly, the people we are all privileged to serve.

¹ Managed Care, Number of Americans who turn 65 every day and become eligible for Medicare: 10,000 (November 2019): https://lsc-pagepro.mydigitalpublication.com/publication/?i=636284&article_id=3538558&view=articleBrowser. ² Centers for Medicare & Medicaid Services, NHE Fact Sheet (Modified August 12, 2022): cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet. ³ Internal data (2022). ⁴ Internal data (2022).

Medicaid Population

See how value-based care extends to the Medicaid population