As more seniors reach the age of eligibility for Medicare, a growing percentage are choosing Medicare Advantage (MA) as their preferred health benefit option. This has quickly made MA the fastest-growing segment of the healthcare market, with 42% of the Medicare-eligible population now enrolled in a Medicare Advantage plan - a 10% increase from just five years ago. This number is only expected to increase, as more seniors age into Medicare and prefer the cost and service benefits that competitive MA plans offer.
Enrollment in Medicare Advantage has more than doubled in the last decade, and half of all Medicare beneficiaries will be enrolled in a MA plan by 2025.
While this growth is exciting news for the Medicare industry, heavy competition and strict government regulations have made barriers to entry incredibly high for new MA market entrants. Just to reach operational readiness and compliance with regulatory measures can present a massive challenge for organizations looking to enter the market.
Despite these obstacles, the burgeoning MA arena presents a huge opportunity for plans that can leverage the operational and technical expertise necessary to handle the administrative and regulatory tasks involved. The following four steps can help new Medicare Advantage plans gain ground in this highly competitive but extremely profitable market.
1. Understand and Comply with MA Regulatory Mandates
The Centers for Medicare and Medicaid Services (CMS) oversee the regulatory compliance that drives the MA industry. Lack of understanding of the complex CMS compliance and regulatory landscape can spell disaster for a new MA market player. Consequences are many but can include sanctions, monetary penalties, enrollment restrictions, and loss of membership. Health plans that are fully prepared prior to entering the market, and that have the necessary processes in place to ensure compliance with constantly evolving industry regulations, stand the best chance of long-term success.
Many new market entrants choose a partner with a comprehensive system with built-in compliance to make sure they’re covering all their bases. They also need to make sure that the vendor is staying up to date on regulation updates and changes on a consistent basis so there’s less stress on the plan to run into any unexpected operational hiccups or fees down the road.
2. Incorporate Data Science into Operational Workflows for Faster Speed to Value
Operational readiness is critical in the rapidly evolving Medicare Advantage market. New entrants must be nimble and place an emphasis on MA-specific administrative processes and data interoperability in order to adapt to ever-changing business and regulatory demands. According to a recent study by BCG, achieving this level of operational excellence depends on having the following technology-enabled elements:
- Robust Utilization and Care Management
By applying predictive analytics to anticipate care demands, payers can take a longer-term view of members' health needs to avoid adverse outcomes.
- Accurate Risk Stratification
To achieve as accurate a view as possible of a patient’s risk, payers need to have best-in-class risk stratification capabilities. This includes models that incorporate self-learning technologies enabled by machine learning algorithms, that increase predictive accuracy over time.
- Efficient and Effective Network Design
Payers currently leading the MA market are pursuing value-based contracts with providers and taking a more strategic approach to structuring the primary-care network for members.
- Improving Performance in the Context of Medicare’s Stars Rating
Plans should coordinate their network design and their Stars strategies to create alignment across the care continuum.
To achieve the above, MA plans need to focus on incorporating predictive modeling and AI into their processes and workflow. By investing in a data science-driven platform with an extensible architecture, Medicare Advantage plans can realize a faster speed to value for their members without increasing the workload for their internal teams.
3. Invest in an All-in-One System that Has Everything You Need
To achieve a competitive position in the evolving MA market, plans need to implement a fully integrated digital solution that breaks down organizational silos across the entire organization. This not only helps operationally it also gives the plan significant long-term cost savings that result from fewer systems and vendor fees.
They can accomplish this in the following ways:
- Research an integrated digital platform with a data fabric that supports fast implementation and data interoperability.
- Craft a digital health ecosystem that allows for seamless integration of best-in-class enterprise and partner-developed capabilities.
- Build flexibility into operations and systems to allow for rapid onboarding of ecosystem partners.
- Leverage AI and machine learning to discover and share actionable intelligence across the entire enterprise.
When a Medicare Advantage plan is empowered by unified, platform-driven intelligence, human capital can be focused on the elements that truly require the human touch, such as member experience and care management.
4. Partner with a Qualified MA Expert
Many plans entering the Medicare Advantage market choose to partner with an expert well-versed in the nuances of MA administration, CMS compliance, and overall health plan business processes. A good partner will have capabilities across the entire healthcare ecosystem - including quality, risk adjustment, utilization management, and care management - as well as the technical expertise to make these systems work together to realize faster speed to value.
Specifically, the right Medicare Advantage partner will:
- Understand all compliance and regulation requirements and be able to advise on the correct course of action around updates and changes.
- Have an all-in-one system that can work with your teams across all departments.
- Feature a robust platform that incorporates data science and predictive modeling for optimal engage-ability and better member outcomes.
- Work within your budget and resource parameters
- Do the heavy lifting in implementation so you can be best set up for success.
As Medicare Advantage continues to lead transformation in the healthcare industry, it’s imperative that plans entering the market embrace emerging trends and innovate in order to succeed.
Click here to talk with one of our Medicare Advantage experts and to learn more about how to thrive in the MA market.
