Medicare Advantage (MA) populations face unique health challenges, and if payers want to gain a competitive advantage in this market, they need to offer a member experience tailored to those specific needs.
Payers operating in the MA market know that this population is more likely than the average patient to have multiple chronic conditions that require complex care. In a traditional fee-for-service model of care, patients often struggle to navigate their care network. Vera’s APC model solves this issue with full care coordination that improves members’ health outcomes and elevates their experience.
Understanding the burden of multiple chronic conditions
MA patients typically present with four to five chronic conditions. And as MA plans expand enrollment of people who have a low-income beneficiary status, a growing proportion of beneficiaries have complex medical needs. In 2012, the average MA patient had 4.5 chronic conditions such as heart disease, diabetes, asthma, arthritis, or dementia. By 2015, that average had already risen to 4.7.
MA patients with a chronic condition are frequently referred to specialists but must navigate the process alone. Sometimes, they may feel unclear about why they’re being referred to a specialist, how to make an appointment, and what to do next once they’ve seen a specialist. Key information that needs to be shared between the patient’s primary care provider and the specialist gets lost in the process.
Now, consider the severity of these challenges when the patient is dealing with multiple chronic conditions. This often means more referrals, more specialists, more confusion, and more information lost.
Managing complex health challenges
How can payers offer their MA members a care experience that is effective, personalized, and easy to navigate?
The key is adopting a model of care that treats each member as a unique individual, rather than defining them solely by their disease or condition. MA populations are varied in terms of the number of chronic conditions they face, the severity of each condition, and external social and economic factors that impact their interaction with healthcare.
In short, MA members need guidance from someone who understands their full biopsychosocial health situation, who coordinates their primary and specialty care, and who guides them towards better health by helping them to develop self-efficacy.
Advanced primary care improves care coordination for MA populations
Vera’s APC model solves the challenge of care fragmentation in a few different ways. First, the APC model is a value-based payment model that is focused on patients’ health outcomes. Second, the APC model allows MA populations to receive 80-90% of their care within the primary care setting, reining in over-utilization of specialty care and simplifying the care experience for MA members. And finally, the APC model is designed to give primary care providers the ability to fully coordinate all the care that MA members receive.
Providers need time and resources to create comprehensive, personalized care plans for each MA member. The APC model provides those resources.
MA members need someone to help them navigate specialty care. In the APC model, primary care providers coordinate and schedule specialty care, as well as follow up to ensure that specialty care is integrated into each patient’s long-term care plan.
A transformed care experience
What does this mean for MA members, especially those with multiple chronic conditions? It means they’re no longer alone. They know where they can go for 80-90% of the care they need. They have someone to help them manage medications and connect with specialty care. They know who to turn to when they have questions about their specialty care. They can trust and rely on their primary care provider to guide them to more effective management of their conditions.