What’s in store for the RISE Association communities in 2021? We asked experts in Medicare Advantage, quality and revenue, consumer engagement, and social determinants of health for their predictions on trends that will impact the industry in the upcoming year. Spoiler alert: COVID-19 will continue to play a big role.
The impact of COVID-19 deferred care
Many health insurers reported record profits on earnings calls in 2020 as the COVID-19 outbreak forced hospitals to postpone or cancel elective procedures and millions of Americans delayed care for both chronic and acute issues. But the U.S. health system will have to absorb the impact of this deferred care in 2021 in a big way, says Dave Meyer, a member of the RISE Advisory Board and Risk Adjustment Policy Committee.
“There will be more units, higher acuity, and sadly, increased mortality due to 2020 deferred care. Whether beneficiaries with social determinants of health have even worse outcomes remains to be seen, but I expect we will find that is the case.”
Payers must prepare to handle the pent-up demand for care this year and in 2022, as well as the higher costs of providing care for members whose chronic conditions worsened during the pandemic. But it’s not only members with controlled chronic conditions who delayed care. Meyer wonders about those who suffered from acute conditions last year. “Where did heart attacks go in 2020? People didn’t stop having them. It is clear that Americans are deferring care across the board. People with mild chest pain would normally go to the hospital for an EKG, and end up on therapy that slows disease progression. Instead, these people are not engaging in care and there will be morbidity and mortality impacts because of it.”
Ana Handshuh, CHC, principal, CAT5 Strategies, and the chair of the RISE Quality & Revenue Community, agrees. She says members didn’t seek preventive care or adhere to treatment plans last year to the extent they would have in a typical year. Some did not feel safe enough to visit their providers. While others were displaced from their medical neighborhoods because they were away from their home, or because their providers were closed or unavailable, or because they could not access the technology needed for telehealth. Because members deferred care they would have otherwise received, many experienced or will soon experience exacerbations of their chronic conditions, leading to more bad outcomes.
In addition, there were many less opportunities to accurately document the chronic conditions that members have (and will continue to have in 2021). Although some organizations did a good job of compensating for this by ramping up telehealth, this will lead to a reduction in revenue as fewer conditions were documented by providers and submitted by plans for risk adjustment. The confluence of these factors is a “terrible combination,” she says. “And the chickens will come home to roost in 2021.”
Finally, since members sought preventive care screenings and other care at lower rates, many plans also expect HEDIS scores to be lower for those corresponding measures. CMS has “solved” for that by using prior year ratings for those affected measures, but those measures would not be counted in the Improvement Measures. This will have far reaching effects in 2022 scores resulting in yet another year of uncertainty and disruption to the Star ratings.
“Adaptability over the next two years will be the hallmark of successful organizations. Plans should not be discouraged because 2020 didn’t go as they originally envisioned,” she says. “And they should continue to look ahead, adapting their priorities, programs, operations, and budgets with a keen eye on CMS’ significant shift in importance to the member experience and access measures.”
A bigger focus on the member experience
Kathleen Ellmore, managing director at Engagys and a member of the RISE Medicare Member Acquisition & Experience Advisory Board, says health care organizations must address three critical focus areas to increase both consumer health engagement and satisfaction:
- Experience and trust: Knowing that member experience will represent almost a third of Medicare Advantage plans’ overall Star ratings by 2023, the need to improve the consumer experience and build needed trust has never been greater. Additionally, trust has become a flash point for the COVID-19 vaccination, current political climate, and health care in general. Building a trusted ecosystem that consumers have confidence in will be critical to reach national and individual health care goals.
- Personalization: Personalization has always been critical in driving behavior change, but recently the stakes are even higher, according to Ellmore. Has a member received only one dose of the COVID-19 vaccine so far or both? Is a member still in lockdown or not? As the landscape changes daily, personalization will become even more critical as plans think about the complexity of understanding where a consumer is and where they need to be along the continuum.
- Plan and provider collaboration: Payer and provider lines continue to blur, Ellmore says. A model of collaboration between plans and providers will be paramount to effectively increase quality and drive more consumer activation. Medicare Advantage plans must understand the role that providers play in member trust and communication and work in concert with provider entities to educate members and break barriers to needed care.
Fortunately, the changing ecosystem offers both challenges and opportunities. “More health care consumers are digital, there is a greater focus on health than ever before, and we have a variety of tools and technologies to drive better engagement at scale,” says Ellmore. “But, if we don’t meet this challenge of true consumer centricity now, and head on, we will be left behind.”
Continued bipartisan support for Medicare Advantage
Despite a new administration and changes on Capitol Hill, Allyson Y. Schwartz, president and CEO of the Better Medicare Alliance, anticipates bipartisan support for Medicare Advantage will remain strong this year.
“Last year, we hit a new record of 75 percent Congressional support for Medicare Advantage, and we’ll work to build on that success in 2021,” she said. “The COVID-19 pandemic has shown just how important this effort is. When crisis struck, Medicare Advantage was ready. As a result, seniors are reporting near universal satisfaction with how Medicare Advantage has handled this pandemic and enrollment is expected to reach nearly 27 million beneficiaries by the end of the year. It is unlikely that there would be any appetite in Washington to disrupt this lifeline for seniors–especially in the throes of a public health emergency–but we will be ready to engage and stand up for beneficiaries when needed.”
Schwartz said she has had productive conversations with members of President-elect Joe Biden’s team, and believes the administration will continue the innovations in the Medicare Advantage program and collaborate on shared priorities, such as addressing racial disparities in health care and social determinants of health and enhancing value-based care for seniors.
“Let’s not forget: the Obama administration presided over four straight years of decreases in Medicare Advantage average monthly premiums and enacted a number of positive changes that strengthened Medicare Advantage,” she said. “The last four years have seen increased enrollment, lower consumer cost, and high consumer satisfaction for millions of Medicare beneficiaries that will not be lost on the new administration. With leadership from President-elect Biden, a 99 percent satisfaction rate from beneficiaries, and support from a supermajority of Congress, Medicare Advantage will continue to drive innovative, quality care for seniors into the foreseeable future.”
Increased attention on mental health
2020 had society striving to cope with COVID-19 and the ensuing pandemic. For 2021, mental health and its accompanying disparities will mandate a shift by organizations to include attention to both the social determinants of health (SDoH) and social determinants of mental health (SDoMH), says Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CCTP, CMHIMP, CRP, DBH(s), who serves as the community chair for the RISE Association’s SDoH community.
This framework will likely transcend efforts to advance integrated care, instead expanding the provider lens to incorporate a wholistic health triad of physical and behavioral health along with psychosocial circumstances, she says.
She sees the following challenges as opportunities for health and behavioral health systems and organizations across every sector:
- Increased incidence of serious mental illness (SMI) among the most vulnerable populations and affected by the virus, with rising rates of major depressive disorder, treatment stigma, increased unemployment, and housing insufficiency for persons with SMI.
- Disaster-related quarantines that imposed negative psychological effects across every age group (e.g., PTSD symptoms, confusion, anger, agitation).
- Deeper levels of economic stress, social isolation, escalating anxiety, and prompting increasing firearms sales, access, and suicide rates across racial and ethnic groups.
- Hampered psychopharmacological care due to prescription access challenges (e.g., delays with renewals, lack of access to telehealth assessments, medication evaluation).
- Far higher incidence of COVID-19 infection and deaths among Blacks, Latinx, and lower socioeconomic groups compared to more socially advantaged populations.
- Rising prevalence of family violence (whether child or adult abuse), domestic violence, and sexual assault, by as much as 80 percent. Safer at home is not a reality for all persons. This leads to a ripple effect for older adults, people of color, individuals who have low incomes and live-in residential facilities. In addition, there is the intersection of COVID and addiction, with program disruption negating access to services and treatment options
- Despite regulatory and payer attention to assure reimbursement for telehealth, the digital chasm remains and mental health is often inaccessible. Poor, limited, or insufficient Wi-Fi access remains a challenge across urban and rural areas especially.
Health plans can address many of these issues in their benefit design. CMS has offered flexibility to allow Medicare Advantage plans to provide new benefits to address SDoH. Plans may also want to seek out vendors who’ve developed programs and services to address member needs holistically, including social determinants, which would also help improve the member experience and access to care.