By skyforbes 
Medicare and Medicaid Trends — Q2, 2024
Introduction:
In the ever-evolving landscape of healthcare, various factors contribute to the challenges and opportunities faced by care delivery and financing organizations especially in Medicare and Medicaid.
From recognizing the pivotal role of family caregivers to embracing digital health solutions, addressing social determinants of health, and navigating the complexities of long-term services and supports (LTSS), the industry is undergoing significant transformations. Additionally, the importance of comprehensive demographic data collection and the adoption of value-based care models are becoming increasingly paramount.
We explore these diverse aspects, highlighting the interconnectedness of these elements and their potential impact on improving healthcare outcomes, enhancing member experiences, and driving cost savings.
1. Policy changes at the federal and state levels are increasingly recognizing the “hidden heroes” among family caregivers. Plans should recognize the role of unpaid family caregivers with direct impact on various healthcare outcomes and measures such as HEDIS measures, CAHPS survey results, utilization rates, and member experience ratings. This will help plans improve NPS (2022 NPS score for health plans is 12% [ XM institute]) and accelerate activation through caregivers (with BEST utilization: ~ 50% of enrollees, TYPICAL utilization: ~ 30%, and WORST utilization: ± 7%).
2. Well designed programs (like Wider circle’s connect for life program) aims to build community-based social support groups for health plan members to address social determinants of health (SDoH), highlight cost savings ($139 PMPM), better quality scores, higher retention, reduced loneliness, and improved outcomes for specific populations like African Americans and pregnant Medicaid members.
3. Around 17% of seniors over 65 are at high risk of frailty. Tilburg Frailty Indicator along with social determinant data can identify at-risk individuals to influence prevention, dementia care, physical activity, home safety assessments, durable medical equipment provisioning, and post-acute care transitions. The annual care costs were 1.5x to 3x higher for high frail compared to non-frail members (e.g. $26k vs $6k for ages 65–69). Yet frailty is underreported by 37%.
4. Sending welcome messages, prompts for health risk assessment (HRA) completion, benefit information, referrals, post discharge follow-up with 40% or more clickable rates can accelerate mobile messaging journey and patient engagement.
5. After Medicaid redetermination, there was a 10–20%+ increase in ACA enrollment, higher premiums, greater coordination with Medicaid and QHP carriers, and increased subsidies (e.g. exchanges auto-enrolled low income households losing covering with 2 months of premium) contributed to historical ACA enrollment (more than 21 million).
6. Health plans face challenges in implementing disease management, behavioral health, and social determinant related benefits. These challenges include IT system issues, lack of reimbursement processes, slow clinical adoption, and lack of interest from members and providers.
7. Physical activity measures have received Level 2 status in the U.S. Core Data for Interoperability (USCDI) as of September 2022.
8. Not managing access leads to over 50% receiving unnecessary GLP-1s first-line at high costs. Proper step therapy could avoid 40% of anti-obesity medication costs and $375-$400 PMPM Rx cost avoidance (according to Vida).
9. The 2030 HP-LAN goals for VBC adoption are Medicare 100%, commercial 50%, Medicaid 50%, with roughly 35% overall commercial payments today on APM (upside or downside or population health). MA leads in adoption of alternative payment models, with 57% of payments tied to APMs in 2022 compared to 41% in Original Medicare.
10. Home care impacts Star measures like Annual Flu Vaccine, Monitoring Physical Activity, Care for Older Adults, Reducing Fall Risk, Medication Adherence for Diabetes and Hypertension, Follow-up after ED visit for chronic conditions, Osteoporosis Management, Plan All-Cause Readmissions, and Transitions of Care.
11. Cell therapy involves transferring intact live cells, while gene therapy involves introducing new genetic material via vectors — either in vivo (non-cell based) or ex vivo (cell-based). These occur in pipeline across various therapeutic areas like oncology, hematology, metabolic, neurological, ophthalmic, dermatologic, and skeletal-muscle conditions. It highlights various precision financing solutions like multi-year performance-based annuities, risk pools, subscription models, and warranties to address the financial challenges of high upfront costs, performance risk, and actuarial risk associated with cell and gene therapies.
12. Engagement with employees is driven by confidence, tools, automation, and clear expectations, while members desired simplicity, communication options, and payment options. This can be achieved by implementing self-service portals, configurable business rules, electronic communications, and payment options.
13. Medicare Advantage is undergoing major shifts due to demographic, regulatory, and financial factors, leading plans to offer more supplemental benefits.
14. Digital health solutions are well-positioned to impact costs and quality, but plans should carefully vet products for validated clinical and financial outcomes, quality measure impact, data reporting capabilities, and effective implementation. Solutions can showcase measurement of risk factors, medication adherence, cost savings, and return on investment through its digital coaching program.
15. LTSS covers 14 million adults and refers to a broad range of paid and unpaid services that assist individuals with functional limitations in activities of daily living and instrumental activities of daily living.
16. Reasons for missing/poor quality data include inconsistent federal guidance, voluntary reporting, outdated systems, and mistrust about data use. Most states lack comprehensive data on sexual orientation, gender identity (SOGI), and self-reported disability status. Improved data allows states like Massachusetts, California, and Oregon have fast tracked through prioritization, aligning with standards, leveraging other sources, addressing bias, and building community trust.
Conclusion
The healthcare industry is navigating a multitude of challenges and opportunities, ranging from recognizing the invaluable contributions of family caregivers to addressing social determinants of health, frailty, and long-term services and supports. Furthermore, the adoption of value-based care models, the integration of digital health solutions, and the importance of comprehensive demographic data collection are reshaping the landscape. By embracing these diverse elements and fostering collaboration among stakeholders, health systems and health plans can effectively improve healthcare outcomes, enhance member experiences, and drive cost savings.