Over half of Medicare beneficiaries in the United States are enrolled in Medicare Advantage (MA) for the first time since its inception, with 31 million seniors choosing an MA plan in 2023.
MA for Tomorrow, developed by IMPACT member The Alliance of Community Health Plans (ACHP), emerges as a visionary approach that challenges the conventional norms of MA to transform the industry and better meet the needs of a growing Medicare-aged population.
Comprised of five strategic pillars, MA for Tomorrow addresses opportunities to increase quality, modernize outdated benchmarks, adopt more effective risk adjustment practices, alleviate consumer navigation challenges, and update network composition standards.
With a mission to drive fiscal sustainability, enhance the quality of care, and tackle geographic disparities, MA for Tomorrow pioneers long-awaited comprehensive reforms.
A new age approach for a new population of seniors
Seniors are increasingly turning to virtual care options for a spectrum of medical services, from remote consultations with healthcare providers to the convenience of monitoring chronic conditions from the comfort of home.
This uptake can be attributed to several factors, including the ease of access afforded by virtual care, mitigating the challenges often associated with in-person visits for an aging population. Additionally, the ongoing advancements that enhance the user-friendliness of virtual platforms, coupled with the necessity of using such platforms during the COVID-19 pandemic, have solidified seniors' confidence in and preference for virtual care.
As seniors experience the benefits of personalized and accessible healthcare solutions, the trajectory indicates a continuous and increasing reliance on virtual care. This shift aligns with the evolving needs of the Medicare-aged population and signifies a transformative wave that is reshaping the landscape of senior healthcare in the United States.
Designed to redefine: 5 pillars of MA for Tomorrow
MA plans are Medicare-approved insurance offerings from private companies that offer bundled inpatient, outpatient, and prescription drug coverage as an alternative to traditional Medicare.
While successful and well-adopted across the nation, MA must continue to evolve meaningfully to improve its quality, risk adjustment processes, and consumer enrollment experience. Careful considerations must be made to ensure a strong foundation of quality, accessibility, and affordability while providing comprehensive coverage and a positive patient experience.
MA for Tomorrow is poised to redefine the future of MA by taking an innovative approach to five distinct focus areas: raising the bar on quality, advancing risk adjustment for care, improving consumer navigation, modernizing network composition, and transforming benchmarks.
These focus areas align with the value of more innovative virtual care models that have emerged as indispensable tools in advancing more effective healthcare delivery. These solutions offer scalable and personalized interventions to address unmet needs and enhance accessibility. Yet, their effective integration into the healthcare ecosystem depends on a modernized approach to longstanding systems such as MA that provides more flexibility for innovation.
Raising the bar on quality
Raising the bar on quality calls for a pivotal shift towards consumer-centric measures, streamlining the star ratings program to prioritize patient experience and outcomes. By eliminating redundant process measures and emphasizing impactful metrics, MA for Tomorrow places consumers at the core of quality efforts, enhancing transparency and empowering seniors to make informed decisions about their healthcare.
Additionally, MA for Tomorrow addresses data collection limitations, strives for accuracy in measuring patient experience for a diverse population, and proposes strategic limitations on high-quality plans, utilizing star ratings and quality bonuses to drive excellence and value.
Advancing risk adjustment for care, not codes
Advancing risk adjustment for care addresses the critical need to refocus risk adjustment methodologies on genuine patient care rather than financial goals. Currently, coding practices prioritize financial gains over quality ratings, creating an uneven playing field for health plans. MA for Tomorrow introduces a strategic risk adjustment program to provide resources for comprehensive care while minimizing opportunities for financial gaming.
This initiative includes recalibrating the risk adjustment model using encounter data, tiering coding intensity adjustments to deter outliers, and targeting Risk Adjustment Data Validation (RADV) audits based on clear criteria to enhance program integrity and protect the Medicare dollar. MA for Tomorrow's approach aligns risk adjustment to deliver quality care to all MA beneficiaries.
Improving consumer navigation
Improving consumer navigation considers the complexities seniors face in choosing healthcare plans, with an average of 44 options available. Seniors often encounter misleading marketing practices, prompting the need for unbiased, navigable information. MA for Tomorrow focuses on reining in misleading marketing by establishing payment caps for health plans to marketing organizations, implementing a fast-track review process for 5-star plans, and strengthening oversight and penalties.
Additionally, it standardizes and limits broker compensation, aiming to foster fair competition and high performance while incentivizing brokers to enroll consumers in high-quality and value-based plans to improve overall health outcomes. This aligns with the new CMS rule for CY 2025 that proposes to redefine “compensation” and establish broker fee limits by setting a fixed amount that brokers or agents can be paid regardless of the plan the beneficiary enrolls in. Collectively, these initiatives create safeguards that aim to empower seniors to make more informed and optimal choices regarding their coverage and care.
Modernizing network composition
Modernizing network composition aims to reshape outdated network adequacy standards for MA plans. The current model, based on time and distance, needs to accommodate the evolving healthcare landscape, particularly with the rise of virtual care. MA for Tomorrow proposes a significant increase in the percentage of a health plan network that can include virtual care providers, recognizing their pivotal role, especially in rural and underserved areas.
The initiative also seeks to streamline the network adequacy exceptions process, providing more precise criteria for exceptions and fostering competition. Additionally, MA for Tomorrow introduces a 'Pick Two' option, offering flexibility in meeting network adequacy criteria by allowing health plans to choose from a set of metrics aligned with modern care delivery expectations. This strategic approach aligns with the digital era, ensuring consumer-centric, accessible, and innovative healthcare in the evolving MA landscape.
Transforming benchmarks focuses on the outdated MA benchmark methodology, which relies on local fee-for-service costs. With a majority of seniors enrolled in MA plans and fee-for-service enrollment shrinking, this approach no longer accurately forecasts care costs.
MA for Tomorrow proposes a transformation, incorporating stronger incentives for high-quality care by removing the benchmark cap, calculating benchmarks using Medicare Parts A and B beneficiaries, blending local and national costs, and restructuring rebates to incentivize quality. These changes aim to ensure fiscal sustainability, address geographic disparities, and encourage MA plans to prioritize and invest in delivering high-quality care.
Planning for tomorrow
The healthcare landscape is rapidly evolving, requiring stakeholders across the industry to remain flexible and adaptive to modern approaches. MA for Tomorrow’s emphasis on updating MA to better meet the needs of patients, including modernizing network composition, acknowledges the limitations of current adequacy standards, particularly in the context of virtual care providers.
“MA for Tomorrow is a well-timed and exciting step towards expanding access to virtual first care for seniors. When it comes to MA network composition, it is essential for the MA program to evolve to embrace the digital era of healthcare. MA for Tomorrow lays that groundwork,”
- Jennifer Goldsack, CEO, Digital Medicine Society
MA for Tomorrow stands at the forefront of healthcare innovation, challenging the status quo and championing high-quality, consumer-centric care. The five pillars represent a fresh perspective to align MA with the evolving needs of seniors and achieve an elevated standard of care. They also codify a value proposition that virtual first care (V1C) providers and digital solutions developers are uniquely positioned to capture.
As the digital health community seeks to address the most pressing and persistent challenges in healthcare delivery, rallying behind a visionary approach focused on ensuring that the payment model chosen by more Americans than any other returns the greatest value will create fertile ground for high-value solutions in the digital era of healthcare.
By eliminating the benchmark cap, recalibrating risk adjustment models, streamlining consumer navigation, modernizing network composition, and implementing a forward-thinking approach to benchmarks, MA for Tomorrow envisions a future where MA doesn’t just adapt to change but becomes a catalyst for positive transformation in the broader healthcare industry. It also creates space for the best of digital innovation in healthcare to return value to the patients our industry exists to serve.
For more information about ACHP and MA for Tomorrow visit https://mafortomorrow.org/. To learn more about what other IMPACT members are doing to lead innovations in virtual first care, visit https://impact.dimesociety.org.