The Centers for Medicare & Medicaid Services (CMS) is transforming payment, delivery, and care in Medicare Advantage (MA) policies. Significant MA investment is fueling enrollment growth and promoting innovation. MA plan sponsors are covering more benefits to improve enrollee choice and quality of care.
2021 MA Enrollment Grew
There are currently 26.4 million members (42% of entire Medicare population), with enrollment projected to reach nearly half of all Medicare-eligible individuals over the next couple of years.
There are over 3800 MA plans nationwide.
Beneficiaries can choose from an average of 39 different plan offerings.
While there has been significant growth in the number of entrants offering MA plans, member enrollment is still concentrated in a small number of national companies.
MA plan priorities may differ, but business models tend to focus on:
Expanding enrollment reach (additional markets) and retaining beneficiaries
Increasing prescription drug affordability with greater eligibility for $0 co-pay and tier 1 drugs
Driving prescription fulfillment to mail order and preferred retail pharmacy networks
Investing in social determinants of care coverage (OTC drugs, food benefits, transportation, dental, vision, hearing, and in-home support)
Expanding access with virtual primary care, behavioral health, and physical therapy
Catering to specific member populations relative to demographics or conditions (eg, plans targeting Asian Americans or African Americans, and plans targeting those with specific health conditions like end-stage renal disease)
These strategies have led to a growing reliance on collaborations with provider organizations such as regional integrated delivery networks as well as joint ventures with long-term care and pharmacy dispensing networks. These collaborations focus on driving innovation in the delivery of care through member engagement and services to improve quality and outcomes. The goals are member retention and new enrollee growth. In addition, improvements in 5-Star quality performance ratings have a direct impact on plan sponsor revenue bonus payments.
The Opportunity for Pharma to Support Care for Patients in MA Plans
This dynamic has created an opportunity for Pharma to engage in deeper customer collaborations with MA plan sponsors and their contracted providers to:
Better support members
Help improve outcomes
Drive results on behalf of brand and related disease state(s)
Collaboration on shared priorities may help build long-term customer partnerships through innovation in the following areas:
Guideline-based treatment regimens
Patient support educational resources aligned to CMS health literacy guidance
Health and care equity gaps/disparities in medication decision-making along the Rx treatment journey
Reimbursement/Hub support services
Transitions of care and integrated provider care teams
Pharma has an opportunity to collaborate with MA plans to improve patient experience and overall outcomes. To ensure success and impact, it will take strategic planning and appropriately aligned resources. The first step for Pharma is to identify a plan and subsequent providers who are aligned in improving overall patient outcomes within a specified therapeutic area. Once objectives are aligned, the collaboration must successfully implement and operationalize the strategy. A plan that supports both patients and providers is vital for success. For example, this can be accomplished by providing patient and provider resources within the clinical workflows via point-of-care electronic health record solutions.
Aventria can help you drive results in Medicare Advantage patient populations by building a credible presence with target MA plan sponsors and their contracted provider networks through an understanding of the MA business model, decision-making, and growing use of technology-enabled patient/provider engagement strategies. To learn how we can help, please reach out to:
Dave Dierk, Co-President, 30-year sales and marketing thought leader in pharmaceutical diagnostics, biomedical, long-term care, managed care, employer, and pharmacy communications, at dave.dierk@aventriahealth.com.
Paul G. Pochtar, RPh, SVP of Pharmaceutical Commercialization and Access Strategies, extensive experience in leading successful market access commercialization of both primary care and specialty pharmaceuticals throughout their life cycle, including several landmark oncology products, at ppochtar@pinnaclehc.com.
Making a difference in patient care by helping patients, providers, and payers collaborate on shared priorities