Kevin Thilborger
Kevin is chief managed care and revenue strategy officer at Unlock Health.
This post continues a series on the state of managed care by Kevin Thilborger. Check out the first post here.
Medicare Advantage (MA) is in a major state of flux, and that has implications for nearly every provider in the U.S. A recent HEALTH CARE un-covered article detailed some of the recent issues.
There was evidence last fall that Medicare Advantage was under attack when several hospitals announced they were reviewing their arrangements with Advantage plan sellers and were not accepting some or all plans. The CEO of the Brookings Hospital system in Brookings, South Dakota, told me, “The difference between original Medicare and Medicare Advantage is vast. Advantage plans pay less, don’t follow medical policy, coverage, billing, and payment rules and procedures, and they are always trying to figure out how to deny payment for services. (HEALTH CARE un-covered, July 8, 2024)
Six months ago, Becker’s Hospital Review reported that at least 16 hospitals, including the one in South Dakota, were dropping some or all of their contracts with Advantage plans.
Becker’s Hospital Review reported in March that a recent survey of 135 health system CFOs indicated that 16% of those systems were planning to stop accepting one or more Advantage plans in the next two years, and 45% said they are considering doing so. Nineteen percent stopped accepting one or more plans last year. (HEALTH CARE un-covered, July 8, 2024)
It’s important to consider the import of this shift. Providers never exit insurance networks that provide volume. Providers never go out of network on a permanent basis if they have a choice. Yet 1 out of every 5 hospitals has already cancelled one or more MA plans, and more are on the way. This reveals something about the sheer difficulty of dealing with these MA plans, and the resolve providers have to choose the right partners.
Unlock Health is leaning-in to the changing MA landscape in several ways. We are helping hospitals and health systems with their MA contracting strategies, selecting the right partners and establishing the right contractual terms and relationships. We are deploying analytics to model contracts and ensuring performance matches expected yield.
When contract negotiations threaten to go sideways, we are setting the tone internally with all stakeholders and then implementing the communication strategy to the external audiences, including patients. Then, we are helping with strong marketing campaigns for health systems or physician groups during open enrollment to help people select the right plan that includes that health system in the network.
Unlock Health is here to help providers set managed care strategy and negotiate contracts in the complex world of payor-provider relations. Our full-service managed care consulting group helps providers set their managed care strategy, negotiate contracts, and handle all the contract modeling, analytics, and contract performance. And when negotiations are difficult or contentious, we pioneered the use of strategic marketing communication campaigns to protect providers’ brands and create pressure on payors for fair and reasonable settlements of contract negotiations. Learn more about our managed care consulting group.