The pandemic has had a tremendous impact on the business of healthcare.  With states canceling elective procedures and people deferring care for fear of being exposed to the virus, hospital and medical practice revenue is down. On the flip side, many health plans are sitting on a mountain of premiums that aren’t being spent because of this deferred care, possibly leading to rebates in some cases and a ton of uncertainty in pretty much all cases. One less obvious outcome of all of this may fall on Medicare Advantage plans in 2021, and it threatens to lower payments by 4-6% in 2021.

Medicare Advantage, of course, is the rapidly growing model that’ll cover more than 24 million Americans this year. According to a recent Avalere report, these plans may be looking at both a sicker population and reduced payments in 2021 because of this deferred utilization. Here to help us understand why, and to share some advice for how Medicare Advantage plans can weather the storm is Dr. Matt Lambert, a practicing ER clinician, and Chief Medical Officer at Curation Health. A few actions Dr. Lambert suggests are:

  1. Focus on the long game and be patient. For example, don’t pay out more to shareholders and, instead, place revenue in short-term investments that they can access without penalty.
  2. Prioritize virtual care/telemedicine enablement/reimbursement now and moving forward. This will enable more members to access care while avoiding in-person treatment risks.
  3. Lead with interventions and the type of claim vs. volume of claims. MA plans will be best served to focus on capturing the key conditions that map specifically to chronic conditions as they drive the most improved outcomes, utilization and costs.

There’s a lot of nuance to this story and the way Medicare Advantage payments are calculated. Dr. Lambert breaks it all down for us. Enjoy!

Dr. Matt Lambert

Dr. Matt Lambert brings more than 20 years of experience as a clinician, CMIO, and change leader in value-based care, ensuring that patients receive more comprehensive care and that payers and providers better capture the value of their services. He is a practicing, board-certified emergency medicine provider who previously founded his own physician staffing company.

Dr. Lambert was one of the founding members of Clinovations. During his time there he served as part of the leadership team for several electronic health record implementations at the nation’s largest public health system in New York City, the University of Washington in Seattle, Johns Hopkins, Barnabas Health, Medstar, and Broward Health. He is also the author of two healthcare books: Unrest Insured (affiliate link) and Close to Change: Perspectives on Change and Healthcare for a Doctor, a Town, and a Country (affiliate link).

Curation Health

Curation Health was founded by a team of healthcare veterans and clinicians to help providers and health plans effectively navigate the transition from fee-for-service to value-based care. Their advanced clinical decision support platform for value-based care drives more accurate risk adjustment and improved quality program performance by curating relevant insights from disparate sources and delivering them in real time to clinicians and care teams. With Curation Health, clinicians enjoy a streamlined, comprehensive clinical documentation process that enables better clinical and financial outcomes while simultaneously reducing clinical administrative burdens on providers. Curation Health takes pride in combining the flexibility and speed of a startup with decades of leadership experience and know-how from roles in leading companies including Clinovations, Evolent Health, and The Advisory Board Company.

Links and Resources

Listen to the interview right here:

Or, find it on your favorite podcast network such as:

Trying to drive change within your healthcare organization? Launching a new product? Having trouble getting decision-makers’ attention and buy-in?

We’ll help you understand the whole picture so that you can align your innovation with the things decision-makers care about. And then we’ll help you execute It’s not easy, but it’s possible and we’ll help you get there.  Sign up here and we’ll keep you up to date on healthcare industry news with podcasts, blog posts, conference announcements and more. No fluff. No hype. Just the valuable (and often not-so-obvious) information you need to get things done.

The #HCBiz Show! is produced by Glide Health IT, LLC in partnership with Netspective Media.

Music by StudioEtar