BY RICHARD FRANK
By relying on virtual cardiometabolic solutions for continuous care, Medicare Advantage can produce better outcomes, curb costs, enhance member satisfaction — and improve Star ratings in the process.
By Richard Frank, MD, Chief Medical Officer Vida Health
Medicare Advantage is a hot market. Enrollment is steadily climbing and Medicare Advantage (MA) members now make up half the Medicare population. Though members keep rolling in, competition among MA plans is tight and turnover remains high. Nearly 16% of MA members switch plans at least once during their first year, while over a third end up switching by year three. Higher-need Medicare members tend to disenroll altogether, impacting Stars ratings.
On top of fierce competition for members, MA plans struggle with ballooning costs as rates of cardiometabolic conditions like diabetes, obesity, and hypertension persistently rise. It’s hard to overstate what a toll cardiometabolic conditions take on our nation’s seniors — especially since those conditions tend to co-occur and compound with age. We’re long overdue for more innovative solutions.
Poorly managed cardiometabolic conditions are significant drivers of MA medical expense trend and spend, member dissatisfaction, and, by extension, poor Star performance. But increasingly, virtual care companies are starting to turn some of those trends around. MA plans should take note.
Virtual care provides value-based pricing and cost-saving interventions
There’s no question that costs associated with cardiometabolic conditions are escalating at an alarming rate. Chronic diseases account for 86% of total healthcare spending in the US, most of which are rooted in cardiometabolic disorders with growing prevalence. Over 40% of Americans have obesity, which increases their risk of developing diabetes six-fold. More than 75% of seniors deal with high cholesterol, and nearly half of adults exhibit high blood pressure, though less than 25% have it under control.
While these chronic diseases cost approximately $3.7 trillion annually in healthcare spending and lost productivity, virtual cardiometabolic care is making a sizable dent to improve health metrics and reduce costs. Many virtual companies are pursuing value-based pricing models that place an emphasis on outcomes rather than simply charging fees for service. Some companies even offer performance guarantees and strategies to reduce healthcare utilization in a medically appropriate manner. By providing access to health coaches and tools designed to help behavior change, virtual cardiometabolic care can prevent unnecessary hospitalizations and even works to get people off expensive medications.
When some of those expensive medications (like GLP-1s for weight loss) are in high demand, virtual cardiometabolic care companies can offer pre-authorization and a clinically rigorous, step therapy approach to keep costs in check while still delivering meaningful outcomes. Health coaches and registered dietitians help manage the side effects of the drugs and guide the necessary behavior changes to sustain results.
Medicare Advantage members value the continuous support and convenience of virtual care
It’s easy to assume that MA members would be reluctant to use tech-based solutions to improve their health. But research shows the opposite is true. Seniors find virtual care solutions convenient and effective, with over 60% of boomers reporting behavioral change success via digital means. Since the pandemic, 50% more MA beneficiaries use virtual care, and overall digital health technology usage has soared.
Obesity, diabetes, high blood pressure, and other chronic conditions take a heavy toll on seniors’ health, mobility, pocketbooks, and overall quality of life. They need more help than brick-and-mortar providers can give. By contrast, virtual care:
- Improves access. More than 1 in 5 older Americans live in rural areas with low access to specialist care. The virtual care no-show is 7.5% vs. 36% for in-office appointments.
- Provides better continuity of care. Provider care teams made up of physicians, registered dietitians, diabetes educators, health coaches, and therapists encircle members and efficiently coordinate care.
- Offers user-friendly tools for success. Remote-monitoring devices and app-based programs help members track progress and gain more health literacy through engaging content.
- Costs less out of pocket. Virtual care doesn’t require fuel, parking, and public transportation costs for members.
Star ratings drive member attraction and retention
Since Star performance ratings play such a crucial role in attracting and retaining MA members, plan leaders need all hands on deck to meet their marks. With Star ratings increasing their emphasis on member experience (Consumer Assessment of Healthcare Providers and Systems, or “CAHPS”) alongside clinical quality as measured by the Healthcare Effectiveness Data and Information Set (HEDIS), MA plans would do well to invest in virtual solutions that offer a continuous care experience members appreciate. Member complaints about health plans may drive the most significant impact on contract performance, so plans will want to avoid those as much as possible.
Many virtual solutions are designed to completely encircle members with specialized care teams to coach through behavior changes, provide personalized eating plans, teach health literacy skills, and even manage medications — prescribing and deprescribing as appropriate. They’re highly effective at keeping members out of the hospital and empowering folks to take charge of their own health.
Medicare Advantage plans could gain a lot from partnering with virtual cardiometabolic solutions that save on costs while producing clinically significant outcomes and placing members at the center of care. After all, healthier MA members make more satisfied MA members, too.
Dr. Richard Frank is the Chief Medical Officer for Vida Health. Dr. Frank is an experienced physician executive with demonstrated success in product development and strategy, managing high-risk Medicare and Medicaid populations, developing new business for established and VC-backed companies, engaging providers in value-based contracts, controlling healthcare utilization, and implementing clinical programs within not-for-profit and publicly traded companies.