The landscape of value-based healthcare in the United States is constantly evolving with Medicare Advantage (MA) playing an increasingly significant role. However, an alarming trend is emerging as greater number of MA members have become complacent in visiting a primary care physician (PCP) or struggle to engage with a trusted PCP for continuing care. In our work with health plans, patients lacking PCP visits negatively impact a health plan’s quality scores and Star ratings.
Across all healthcare industry stakeholders, there is a pressing need to address this growing concern: MA members without primary care physicians (PCPs). This cohort, called the MA Primary Care Gap, may present the highest risk to health plans as MA becomes their fastest-growing segment according to a recent Health Affairs study.
Furthermore, the MA Primary Care Gap is widening due to industry shortages of primary care providers and the rise of healthcare deserts in both rural areas and under-served urban areas. The absence of primary care physicians is particularly troublesome for Medicare Advantage patients with multiple chronic diseases and complex healthcare needs.
A study by the National Institute of Technology revealed that the concentration of complex patients ranged from 25.9% to 68.9% in MA contracts. These patients, who account for 55% of total health plan spending, pose a significant investment in the cost of care.
When complex patients are not under the guidance of a PCP, the risk to both cost and quality of care doubles due to lack of consistent primary care and health screenings. To address the issue, health plans must effectively engage this patient population.
As we approach 2024, the question looms: How can health plans engage MA members to connect them with PCPs, ensure proper follow-up care, and close the MA Primary Care Gap?
Health plans must adopt best practices to reach and engage MA patients, especially those with multiple, complex conditions. Here are six best practices to consider.
- Source public and private data to help find and engage MA members who lack a PCP.
- Conduct omnichannel outreach to engage highest risk members (complex medical patients) as soon as possible for optimal intervention.
- Use local phone exchange numbers to provide familiarity and increase engagement. Nearly 70% of Americans ignore unrecognized phone numbers.
- Understand the common reservations that MA members have when interacting with their health plan. They may be distrustful of potential bill collectors or the legal ramifications of disclosing health and social needs.
- Build trusted relationships with high-risk members through various channels such as phone, email, and if necessary, onsite outreach during their preferred engagement hours of the day. Establishing trust is pivotal to ensuring these members receive interventions.
- Go beyond giving the MA member a local PCP contact number. Take additional steps to ensure the member makes an appointment. For example, book three-way phone calls, send appointment reminders and follow-up messaging, and secure proper transportation to the appointment.
Implementing these methods has demonstrated proven outcomes in other member populations. When these strategies were employed to engage hard-to-reach Medicaid members, engagement rates increased significantly, resulting in a 1-star improvement for the health plans involved. Examples include:
- 43% uptick in Medicaid and Dual Special Needs Plan (DSNP) member engagement for redeterminations
- 84.3% statin medication adherence improvement
- 57% conversion of inactive members for successful SDOH screenings
- 247% increase in PCP appointments for a patient-centered medical home program
The urgency to close the MA Primary Care Gap is palpable, and health plans must take proactive measures to ensure the well-being of their members and the sustainability of their programs. By implementing best practices and data-driven interventions, health plans can navigate the challenges. The key to success lies in recognizing the risks, engaging high-risk members effectively, and building a healthcare system that prioritizes primary care for all.
Photo: erhui1979, Getty Images
