Karen Appold

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Where people work, live and play can greatly affect their health and the quality of healthcare they receive. Research already has shown that these social determinants of health (SDOH) are potent. Now researchers are digging deeper and learning how SDOH affect diseases, including risk for certain cancers and their outcomes after treatment, says Katherine Reeder-Hayes, M.D., M.B.A., M.S., chair of the American Society of Clinical Oncology’s Health Equity Committee. The considerable differences between poor and wealthier patients, as well as between Black and White patients, can often be traced to SDOH, says Reeder-Hayes, who is also an associate professor and chief of breast oncology at the University of North Carolina-Chapel Hill School of Medicine.

Here’s a closer look at how SDOH affect cancer rates in certain populations, how these disparities influence cost and payment of cancer care, and how new payment models are better addressing SDOH.

According to American Cancer Society research, Black males have the highest cancer incidence (549 per 100,000) and death (240) rates of any group identified by race and ethnicity and by gender. Black females have higher cancer death rates than non-Hispanic white females despite a lower incidence rate.

Comorbidities such as diabetes, chronic obstructive pulmonary disease, hypertension, obesity and heart disease affect cancer treatment options and outcomes. Black patients have higher rates of comorbidities, some of which can be attributed to SDOH. Obesity, for example, is more common among Black women and is a risk factor for endometrial cancer. Obesity is linked to SDOH such as food affordability and access to healthy food options or safe spaces for physical activity in patients’ neighborhoods, notes Reeder-Hayes.

Some of the largest racial disparities occur in breast, prostate and colorectal cancers. “It’s notable that all of these cancers are screen-
detected, and that social determinants at the health system level and individual level — such as access to insurance, proximity to a screening facility, availability of time off work or transportation — can all affect how likely someone is to get screened and therefore how early their cancer is caught and their chance of being cured,” says Reeder-Hayes. But incidence and mortality patterns differ among cancers. For instance, the risk of prostate cancer for Black men is much higher than for White men, whereas breast cancer incidence among Black women and White women is roughly the same. However, the mortality rate for both cancers is higher for Black patients, which appears related to differences in access to treatment, Reeder-Hayes says.

Insurance coverage is another variable in access to cancer treatment. A 2017 study found that only 41% of plans sold on the ACA exchanges had networks that included one of the 71 cancer centers designated by the National Cancer Institute.

“A patient’s choice to go to a top-tier cancer center was essentially cut off because they had insurance through the Affordable Care Act, which, in turn, disproportionately insures minority and lower-income patients and the working poor,” says Reeder-Hayes. “This is an example of social determinants working through the structure of the health system to shunt certain patient groups toward or away from certain types of care — often away from higher quality care.”

Keely Macmillan, M.S., senior vice president for policy and solutions management at Archway Health in Boston and a member of the 

® editorial advisory board, says oncology payment systems haven’t done enough to incentivize care that would address health inequities. “This is partly a reflection of outdated fraud and abuse laws that are prohibitive to innovative ways to address SDOH,” she says. For example, healthcare providers might run afoul of the federal Anti-Kickback Statute if they were to offer transportation or housing assistance, because the statute prohibits offering anything of value in order to get business.

Some good news is that new payment and delivery models are being designed to improve the effectiveness and efficiency of specialty care, including cancer care. CMS’ Center for Medicare and Medicaid Innovation (CMMI) developed the Oncology Care Model (OCM), which aims to incentivize higher quality and more highly coordinated oncology care at the same or lower cost. Under this model, physician practices have entered into episodic payment arrangements that include financial and performance accountability for the total cost of care for patients undergoing chemotherapy.

CMS is also partnering with commercial payers under the model. Practices participating in OCM have committed to providing enhanced services to Medicare beneficiaries, such as care coordination, navigation and national treatment guidelines for care. As of the beginning of last year, 138 practices and 10 commercial payers were participating in OCM.

Some features of OCM could potentially address health equity issues, says Macmillan. Program requirements include a documented care plan for each patient containing the 13 components of the Institute of Medicine’s Care Management Plan, including estimated out-of-pocket costs and a plan to address psychosocial needs. Providers who participate in the model receive real-time monthly enhanced oncology services payments — above and beyond fee-for-service payments — to effectively aid in managing and coordinating patient care. Practices can use this additional funding to hire social workers, patient navigators, community health workers and other staff to support patient care plans.

Other features of the OCM’s pricing methodology that might start to address health inequities include an upward price adjustment for patients who are eligible for Medicaid or who qualify for a low-income subsidy. The adjustment reflects higher costs that come with social risk factors, Macmillan says. In addition, an OCM risk adjustment is scheduled to go into effect February 2021 based on whether the patient has metastatic cancer at diagnosis, according to Macmillan. Because Black patients are more likely to receive a diagnosis of metastatic cancer, the risk adjustment might translate into higher-quality care for Black patients with cancer.

OCM also ties part of the payment to providers to the number of comorbidities a patient has, which acknowledges that care for patients with cancer who have comorbidities may be more complex and expensive, Macmillan says. Because many comorbidities can be traced to SDOH, the additional payment is an indirect way of addressing SDOH in the context of oncology payment.

Incorporating a greater focus on SDOH through value-based payment models that are designed to reward quality of care over quantity could help close the widening disparity gap, says Melanie Teske, senior director of provider payment and network innovation at Blue Cross and Blue Shield of Minnesota. The Minnesota insurer is putting a strong focus on shifting to value-based payment models that enable reimbursement based on health outcomes instead of just the number of billable services provided. As a result, providers are rewarded for addressing SDOH issues outside of services paid for under traditional fee-for-service payment, Teske says.

“Value-based payments incentivize healthcare providers to develop and implement care delivery plans that address health inequities and close gaps in care related to SDOH,” says Teske, who says the Minnesota Blues plan is in the early stages of implementing SDOH programs through these agreements. Teske said the insurer created a pilot program with one local care system in 2020 aimed at measuring the impact of SDOH screenings and refining the payment model accordingly. The Minnesota insurer is planning to expand this and other SDOH-
focused payment models broadly in the near future.

The alternative payment models that CMMI has created include waivers to fraud and abuse laws under certain conditions. “However, it is challenging for providers to implement initiatives to address SDOH when the waiver only applies to a subset of their patient population and when they’re unable to reliably identify attributed patients protected under the waiver,” Macmillan says. “With recent reforms to Stark law [the Physician Self-Referral Law], the Anti-Kickback Statute, and Beneficiary Inducement Civil Monetary Penalty Law, hopefully, there will be novel approaches implemented to achieve health equity.”

Other payment models go further in addressing SDOH. CMMI’s new Direct Contracting Model allows direct contracting entities to offer beneficiary engagement incentives, subject to certain limitations, including vouchers for transportation services, vouchers for nutrition and meal programs, telehealth, and other items and services to support chronic disease management, Macmillan says. CMMI has another payment model, Geographic Direct Contracting Model, that allows providers to offer additional enhancements, including subsidies for Part B premiums, Macmillan says.In the Oncology Care First model, a successor to the Oncology Care Model, CMMI announced its intent to continue paying prospective payments for enhanced services. “These capitated payments could be used to address SDOH,” Macmillan says. More information on the new model is expected in spring 2021.

The Program of All-Inclusive Care for the Elderly, a joint Medicare-Medicaid program designed to keep senior citizens living in their homes, is another payment model that can result in resources going toward mitigating harmful effects of SDOH. Participants and their caregivers meet with an interdisciplinary team that includes physicians, nurses, therapists, social workers, dietitians, personal care aides, transportation drivers and others, Macmillan says. Their needs are assessed, and an individualized care plan is developed.

Although some see the aperture of oncology payment slowly beginning to widen to consider SDOH, the focus remains on medical services. In future models, Macmillan says CMS must adopt better ways to account for the effect of SDOH on cost: “The current methodology relies on comorbidities that have been previously documented, and SDOH can inhibit access to care and reduce the likelihood that comorbidities have been previously documented.”

According to Reeder-Hayes, “The strongest predictor of a patient’s chances of beating cancer should not be his or her location, race, income or occupation. Every person deserves a fair opportunity to get high-quality cancer care that’s matched to their needs and values. With some of the most advanced healthcare technology in the world, that is possible.”

“We need to figure out how to design the health system to deliver that fair opportunity,” Reeder-Hayes continues. “If we care enough to invest in data collection about the social circumstances of patients, measure differences in the care delivered based on social factors, make adjustments based on findings, try again and remeasure, we can continue to learn how to be better.”

Along these lines, Manali I. Patel, M.D., M.P.H., M.S., assistant professor of medicine at Palo Alto Veteran Affairs Health Care System, says it will take a village to overcome barriers influenced by SDOH on cancer payments. “It’s important to consider how to ensure that SDOH are identified for patients,” she says. “In some cancer settings, navigators or community health workers have served in that role. Addressing SDOH requires a team-based approach between patients and their caregivers, oncology providers, community-based organizations, payers and policy makers to ensure that multi-level interventions are enacted.”

Karen Appold is a medical writer who lives in the Lehigh Valley region of Pennsylvania.

Articles

Adjustments to payment models are beginning to take social determinants into account. 

SDOH: How They Affect Cancer Rates, Care and Payment

Behavioral economics is the study of how individuals analyze economic choices and make decisions. It recognizes that they are not the rational, reasoned people described in classic supply-and-demand economic theory. Instead, because they are emotional and full of cognitive quirks, they do not weigh risk-and-reward issues very well.

“The goal of behavioral economics is to identify the various triggers that shift behavior and then use those triggers to create an environment that makes it easier for individuals to make healthy decisions,” says Rick Leander, CEO of LFB Holdings, a behavioral insights consulting company in Winston-
Salem, North Carolina.

Within behavioral economics, techniques and programs exist to help people make decisions that are presumably better, or at least more rational. The health insurance industry has used these tools to influence behavior in various ways.

One tool is the nudge, a slight tweak of the environment to guide decision-making. Health insurers can use nudges to get members to choose in-network care over out-of-network care by decreasing coverage of the latter. “While the insured party can still choose an out-of-network provider, the higher price orients them toward an in-
network provider,” says Preet Anand, co-founder and president of Snug, an app-based daily check-in service for seniors living alone.

Another tool, hyperbolic discounting, offers something for a limited time after which the offer is gone, says Lisa Freeman Foote, M.A., director of health engagement design at HMS, a healthcare technology company based in Irving, Texas. Freeman Foote says an insurer might, for example, tell members with diabetes, “ ‘We have a limited number of free kits to send to members today to help them manage their blood sugar. Would you like one, before they are no longer available?’ The key is to create a sense of urgency.”

Another tool in behavioral economics plays on people’s perceptions of time. Often that means strategically timed emails and text messages to help jog the memory. “For many people, time passes quickly without them realizing it,” Freeman Foote says. “This causes them to sometimes forget that they need to do something because they feel like they just did it.” For example, a woman might forget that it has been two years since her last mammogram.

One of the most noted success stories in behavioral economics concerns organ donations. There is a dearth of critical organs for transplant, both domestically and internationally, says Thomas Rice, Ph.D., a professor at the UCLA Fielding School of Public Health in Los Angeles. States and countries have set “organ donor” as the default on driver’s licenses as a way of increasing donors.

Researchers have found that people rarely choose the cheapest health insurance plan, even when the benefits of alternative plans are identical. When plan benefits are not identical, people often do not comprehend the differences because of cognitive overload. “There are ways to cut down on information overload, including reducing the number of choices available to a manageable number by removing uncompetitive or unpopular plans, removing extraneous information from comparison tables … and using star ratings rather than exact dollar figures to catch the eye,”
Rice says.

But researchers have discovered that the success of interventions predicated on behavioral economics is sensitive to context — meaning what worked in one environment may not work in another, even if the new environment appears identical. “Every intervention should be viewed as a way to learn, to get smarter and to test assumptions that earlier interventions may have supported,” says Leander. “Most behavioral economists consider every one of their interventions an experiment.”

“I am a huge fan of Paul Saffo’s concept of strong opinions weakly held,” Leander continued. “We know that every opinion is based on incomplete information, and that a smart way to think about that reality is to be willing to formulate an opinion based on early and incomplete information and then systematically look for insights that would tear that opinion apart.”

hints at the limitations of behavioral economics. Neither reminders from electronic pill bottles nor bidirectional text messaging about medication adherence improved blood pressure control. But Anand does not see the study as evidence that behavioral economic interventions don’t work, because there was already a high level of adherence. “There was very little to improve upon, especially because there were only 150 people in the study,” he says. “In general, medication adherence is thought to be around 50%. (Those are) the conditions and control I would test this against.”

Freeman Foote notes that the goals of the two different messages being sent to the pill bottle group were to provide encouraging nudges to either celebrate the “victory” of taking the pill yesterday or to urge people to take it today, she says. “There is room to improve the messaging by providing stronger language,” says Freeman Foote. “If they tested different messaging, they may have seen that by addressing the severity of not taking the medication exactly as it should be taken. There may have been shifts in adherence or blood pressure levels.”

The COVID-19 pandemic has led to an unexpected increase in the use of telehealth. Freeman Foote says behavioral economics could provide some useful insights into telehealth usage and those who are reluctant to use it: “If we could ascertain more about people’s motivations or lack thereof by addressing barriers, then smart communications and content could be developed using behavioral techniques to continue growing adoption.”

When reflecting upon the successes and failures of behavioral economics used in healthcare, Freeman Foote says she has learned the pitfalls of generalizations. “It’s important to develop tailored and specific communications to meet individuals where they are in their current healthcare journey and plan for that unpredictability,” she says. “There will never be a one-size-fits-all solution, because all people act differently. When taking a more personalized approach, the odds of driving positive behavioral change are greatly increased.”

Leander has learned that shifting behaviors is difficult. “People are wired for instant gratification, yet in healthcare we often ask people to shift behaviors now for benefits that will not show up for years or decades, such as ‘don’t drink sugary sodas to avoid getting diabetes in 20 years.’ We need to find ways to provide shorter-term benefits for these kinds of behavioral shifts.”

Rice has realized that it is difficult to predict how effective a new behavioral economic strategy will be because there is no underlying theoretical model that helps gauge the impact of specific interventions. “One thing that’s great about behavioral economics is that interventions are often very cheap compared to traditional economic incentives,” he says. A study in Africa, for example, found that if a person with HIV has a good chance of winning a very small prize in a lottery, they are more likely to take antiretroviral medications.

The bottom line is that many principles of behavioral economics can be applied to healthcare. “Some work better than others, but all of them have their place and purpose and should be applied and tested appropriately in the industry,” Freeman Foote says.

Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania.

Insight into people’s irrational choices can improve healthcare.

Using Behavioral Economics to Influence Healthcare Decisions

When the COVID-19 pandemic spread to the U.S. last spring and the country went into lockdown, the utilization of healthcare services came to a screeching stop. Many experts are concerned that this “hiatus” will lead to greater illness — and healthcare costs — this year because care, especially for chronic conditions, was deferred or canceled.

Another unintended consequence of COVID-19’s hitting the pause button may be the elimination or attenuation of “low value” care: the wasteful tests, prescriptions and procedures that result in little, if any, improvement in outcomes. By some estimates between about $75 billion and
$100 billion is spent on low-value care and overtreatment each year, a relatively small fraction of the $3.6 trillion in annual healthcare spreading but, nevertheless, a great deal of money. Some experts see the pandemic and the resumption of healthcare as a rare opportunity to reset U.S. healthcare without so much low-value care.

Low-value care takes many forms. Walt Ellenberger, a senior director of healthcare business development and innovation at SAP, a software company, lists a few classic examples: overprescribing brand-name drugs when generics are available, prescribing antibiotics for viral infections and moving too quickly to surgical procedures for conditions such as back pain that can be managed with medications or physical therapy. The Choosing Wisely campaign launched by 

 and the ABIM Foundation in 2012 is aimed at rooting out low-value care. The publication and the foundation have worked with the specialty societies to develop lists of tests and procedures for physicians and patients.

Low-value care has ripple effects beyond the direct cost of care that doesn’t improve health. Low-value services may have harmful adverse effects. And they can trigger a cascade of follow-up tests or services that can lead to anxiety; the risk of still more adverse effects; and, of course, more higher healthcare costs.

Some experts see low-value care commanding resources that might otherwise go to more healthful interventions. “This unnecessary spending crowds out resources available to pay for high-value care or other important priorities outside of healthcare, such as education and transportation,” says Corinna Sorenson, Ph.D., M.H.S.A., M.P.H., an assistant professor of population health sciences at Duke University School of Medicine in Durham, North Carolina.

Says Ellenberger: “Many clinicians are already overburdened. Removing unnecessary testing and procedures frees them up for work they really need to do. It also frees up resources in the laboratory and diagnostic departments, which helps move patients through the health system more efficiently.”

Patient demand is one of the causes of low-value care. People are swayed by advertisements or believe that a low-value intervention is effective — the antibiotic prescription for a viral upper respiratory infection, for example. But, as Ellenberger notes, unnecessary services can backfire, lowering patient satisfaction and eroding trust in providers. “That can manifest itself in distrust in a specific provider or distrust in the entire healthcare system,” he says. “Either way, it can lead to poor outcomes and higher costs later.”

Physicians and other providers order low-value tests, treatments or procedures for a wide variety of reasons, says Sorenson, ranging from the inertia around established clinical practices and workflows to the volume incentives inherent in fee-for-service payment to fear of malpractice.

When the pandemic first hit in March/April 2020, many hospitals and other providers pivoted to tests and procedures that were needed most and postponed elective procedures (although how “elective” they really are is open to debate). Furthermore, many people avoided going to the hospital or doctor for nonemergency health issues because they didn’t think it was worth the risk of infection. “Although this likely prevented them from receiving tests and scans they didn’t need, on the flip side, many people likely suffered because they didn’t get necessary care,” says Vikas Saini, M.D., president of Lown Institute, a healthcare think tank in Brookline, Massachusetts, that focuses on low-value care.

Sorenson says that some people may never seek out low-value care that was postponed. She also notes that the pandemic may shift perspectives on what care is truly necessary and whether there are better ways of delivering care that lowers costs and improves, or at least maintains, health outcomes. That said, Sorenson says the industry is at high risk of reverting back to “business as usual” given the pervasiveness of low-value care in American healthcare, partly because many providers are under financial strain.

But there’s an opposing point of view that disruption wrought by the pandemic is likely to mean less low-value care. David Nickelson, Psy.D., J.D., vice president of client growth-healthcare for Nerdery, a digital business consulting firm, believes healthcare won’t return to the way it was before COVID-19. “There has been an immense growth for digital health services as well as an emphasis on using data to improve the patient experience that will reduce the use of low-value services,” he says. “Many more people are now willing to receive services via telehealth or virtual care platforms, which can free up healthcare providers to focus on more pressing challenges or critical patients.”

This more optimistic take on the pandemic is that it has served as a kind of seminar of teachable moments about low-value care and a host of other festering issues. “It exposed the vulnerabilities of a healthcare system designed to be reactive in treating patients,” Ellenberger says. “A fragmented industry used to working independently had to collaborate with other stakeholders to effectively combat a common enemy in order to survive.”

Sorenson says the pandemic exposed long-standing flaws in the healthcare system, such as its fragmentation, inefficiencies and glaring disparities, as well as how susceptible these flaws leave the system and economy to crisis. But she also sees some positive developments: The pandemic has showcased that, with sufficient will and collective action, the healthcare system can make innovative payment and care delivery changes swiftly as long as there are sufficient will and collective action. Sorenson points to telehealth and coverage for its use: “Coupled together, there seems to be a growing awareness that we don’t want and can’t afford to return to our pre-pandemic health system.”

Sorenson says that the pandemic has created a natural experiment to better understand the short- and long-term impacts of eliminating low-value care on health outcomes, quality of care and costs. Rather than just springing back thoughtlessly to prior practices, she says steps should be taken to sideline low-value care. “If a service is truly low-value care (and its absence will have) minimal or no negative effects on health or quality of care ... steps should be taken to ensure it’s not reintroduced into the system or, at minimum, its use should be reduced,” she says.

NEJM Catalyst Innovations in Care Delivery

 in August, Sorenson and three of her colleagues at the Duke-Margolis Center for Health Policy suggest the development of “do not restart” lists to educate providers and patients about low-value care services that should not be reinstated. Other possibilities include low-value services and reminders in electronic health records and clinical decision support tools that steer providers away from ordering or using low-value care services. Low-value care can also be discouraged by upping patient cost sharing while decreasing cost sharing for high-value care, notes Sorenson.

One of the truisms of the COVID-19 pandemic is that it accelerated the shift from in-person care to digital platforms. That switch, many believe, can help rid the system of some low-value care. “Relying on data-driven systems that transfer information more quickly to healthcare professionals and prioritizing patients’ needs will improve the overall quality of care in the healthcare system and reduce unnecessary or low-value services,” Nickelson says.

Nathan Ray, director of healthcare and life sciences at West Monroe, a management and technology consulting firm headquartered in Chicago, says that COVID-19 highlighted the possibility for sustained virtual care. “It has allowed for the reduction of volume, meaning not less interaction but, rather, more timely interaction with physicians,” he says. “Consequently, more patients can get the drug or therapy they need faster than booking multiple in-person appointments.”

Farzad Mostashari, M.D., Sc.M., is co-founder and CEO of Aledade, a company that operates accountable care organizations with and for primary care practices. He says that the value-based care that his company implements is built “to support virtual care tools in a responsible, high-value way.”

The pandemic, in Saini’s view, may also speed the move away from fee- for-service to value-based payment: “I foresee a greater openness and interest in capitated payment models in which providers are paid a flat fee per patient per month.”

Sorenson says that the COVID-19 pandemic has shown that value-based care and reducing low-value may go hand in hand. “Providers practicing within these models have been more successful in responding to the pandemic and weathering the ongoing economic uncertainties as a result of more predictable financial structures and associated investments in infrastructure, staff, programs and data systems to improve population health and care delivery,” she says. “These same capabilities are needed to reduce low-value care in the long term.”

Some see the decline in healthcare utilization as an opportunity to eliminate ineffective, sometimes harmful healthcare.  


Will COVID-19 Wring Low-Value Healthcare out of the System? 

Enrollment in Medicare Advantage (MA) plans has doubled over the past decade, and today the insurer-run plans cover more than 24 million Americans. Almost one-third of Medicare beneficiaries are now enrolled in MA plans, and that number is expected to grow as the baby boomers age into Medicare coverage.

Insurers see a large and growing line of business in MA. For beneficiaries, the simplicity of having coverage provided by a single plan is appealing. The premiums are low — and more than half of the MA plans in the United States have no monthly premium at all. Often additional coverage (dental, hearing) and other benefits (gym memberships) are also thrown in. The trade-off for the enrollees is a narrower network of providers and sometimes some copays and coinsurance.

The growth of MA is not without its critics. They see MA’s growing share of the Medicare population as a drift toward the privatization of Medicare — or at least the management of the program. Insurers are raking in large profits because of overly generous federal government payment, they say. The rebuttal from the MA plans and their backers: MA brings the value, care coordination and focus on the social determinants of health (SDOH) that is sorely lacking elsewhere in American healthcare.

“This steady growth is likely due to the value and financial stability of these plans,” says Britta Orr, J.D., M.P.H., chief Medicare officer at Allina Health Aetna in suburban Minneapolis.

Over the years, MA plans have moved to address the physical, emotional and social needs of seniors and those eligible for Medicare because of disability, notes Susan Smith, senior vice president of the retail segment of Humana Medicare in Louisville, Kentucky. Smith mentions the gym membership, the MA perk that may be more common than important, and efforts to manage chronic health conditions. Additionally, a focus on SDOH has led to a greater emphasis on ensuring that members have enough healthy food to eat and access to programs that help them deal with loneliness and social isolation, Smith says.

MA plans may be especially attractive to people aging into Medicare who have had coverage through their employer and want to continue with the same insurer. Because Cigna has many members in its employer-sponsored plans, when these customers transition to Medicare, the insurer has the opportunity to offer continuity of care — and serve individuals throughout their lifetimes, says Aparna Abburi, president of Medicare Advantage at Cigna.

Tami Hibbitts, MBA, vice president of Medicare at Priority Health in Grand Rapids, Michigan, points to the appeal of MA coverage of preventive care, including annual health exams and a variety of screenings. Christopher Ciano, who oversees Aetna’s Medicare Advantage plans, mentions customization. “By offering access to added benefits that can be tailored to support individual members’ unique lifestyles and total health needs, these (MA) plans are often referred to as a one-stop shop,” he says.

Financial incentives — and responsibilities

The MA plans say their preventive and SDOH efforts aren’t just selling points. “MA plan offerings and robust supplemental benefits lead to better health outcomes for members,” Hibbitts says.

“It’s a win-win for everyone — the government, insurers and members,” says Andrew Toy, president and chief technology officer at Clover Health in San Francisco. “Our goal is to keep our members happier, healthier and out of the hospital.” Clover partnered with Walmart this year to market MA plans in eight counties in Georgia that give members access to services at Walmart Health clinics with no copays.

Orr says taking on the financial risk of its MA members incentivizes Allina Health Aetna to keep coverage simple, personal and affordable. “The MA model challenges private insurers to provide high-quality networks, to promote population health and prevention, and to effectively coordinate patients’ care,” she says.

Still, the MA plans are dependent on government funds and Medicare, more specifically. “We take our stewardship of taxpayer dollars very seriously,” says Cigna’s Abburi says. “MA has traditionally been a pretty low-margin business.”

As with any government program, Orr says it’s important to strike the right balance between compensating Medicare plans sufficiently for the value they deliver and driving continuous improvement to quality and efficiency metrics.

Meanwhile, insurers continue to add new services to their MA plans to make them more attractive as the competition among MA plans heats up. According to the Kaiser Family Foundation, the average Medicare beneficiary had 33 MA plans to choose from during the enrollment period for 2021 coverage, which ended on Dec. 7.

Hibbitts says Priority Health believes that being healthy goes beyond visiting a doctor when you don’t feel well — it’s about practicing healthy habits every day. Next year the company’s MA plans are giving members free access to BrainHQ and its online brain exercises designed to improve memory and overall cognitive function.

Ciano describes several innovations in Aetna’s 2021 MA plans. For example, some are removing the requirement that beneficiaries designate a primary care physician. Instead, they can visit a nationally contracted walk-in clinic or CVS MinuteClinic location — CVS owns Aetna — and pay the same copay as a regular visit to a primary care provider.

All of Aetna’s 2021 MA plans will offer an annual in-home assessment at no cost that includes a comprehensive health risk assessment and noninvasive physical exam. The clinician will also assess the home environment for potential fall risks.

Aetna is also expanding its companionship benefit to address social isolation in select plans in six states. Aetna has hired a company called Papa Inc. to connect college-age young adults with older adults who need companionship and help with light housework and technology problems. Aetna also has a number of initiatives targeting the SDOH of food insecurity, including one that gives the members of some of its plans a “healthy food” debit card that gives the member a monthly allowance to purchase approved healthy food.

Insurers don’t want to miss out on MA’s enrollment growth, so they are expanding into new markets. Cigna, for example, branched out and marketed 2021 MA plans in markets in five states — Ohio, Virginia, Oklahoma, Utah and New Mexico — for the first time while also expanding into new markets in states where it already has a presence.

When mapping out its expansion plans, Humana identifies areas where people with Medicare may be underserved with current offerings. “We’re already one of the largest MA organizations in the country based on membership, so there aren’t as many places for us to expand,” notes Smith. UnitedHealthcare has also gone into expansion mode, marketing 2021 MA plans in 291 additional counties. This is the company’s largest MA expansion in five years, according to Steve Warner, senior vice president of Medicare Advantage at UnitedHealthcare Medicare & Retirement.

Many of the large insurers are responding by expanding into new markets.

Karen Appold

Articles

SDOH: How They Affect Cancer Rates, Care and Payment

Using Behavioral Economics to Influence Healthcare Decisions

Will COVID-19 Wring Low-Value Healthcare out of the System?

Medicare Advantage Enrollment Keeps Growing