Analyzing Medicare Advantage Profitability

Here’s a big thing that Betsy Seals makes clear in this show: Big companies can be successful in Medicare Advantage (MA)—and I mean success in all of its financial glory—because they have experience and the scale and also the specialized departments who keep track of all kinds of intricacies that are rate critical to MA success. Specifically, things Betsy Seals talks about as critical success factors, for example, are having relationships with brokers and health systems and other provider organizations. She also makes it clear how much local market knowledge is necessary. A benefit design working great in one local market might be a medical trend disaster in another area with different levels of social determinants of health (SDoH) or different disease patterns, so scaling into new areas isn’t a matter of just cutting and pasting. History has shown it’s easy enough to go down in a flaming ball of unanticipated medical trend and/or OIG/DOJ scrutiny.

So, this is one thing that big MA carriers can get right and potentially, for sure, benefit patients in their plans. Now I say this knowing full well that there’s a brouhaha afoot in which there are some who are really pro-MA and there are some who are really not. In this show with Betsy Seals today, we do not get into this (ie, Do patients in MA plans fare better than patients in traditional Medicare?). But I have a point to make, and I’m just gonna make it here.

Like most “Is this better than that?” questions in healthcare, there is not one answer; and anyone running around espousing pretty much anything as a broad-stroke holy grail is pretty much full of it—and I would say that as a general statement. Whether MA is better than traditional Medicare depends on who the patient is and also which MA plan we’re talking about here.

So, starting on the “not a fan” side of the house, Wendell Potter has said (with evidence) that if a patient is toward the end of his or her life or acutely ill or needs to go to an NCI-designated cancer center, it could easily be deduced that traditional Medicare is going to be better.

On the other hand, there seems to be evidence, including a recent JAMA article by Ravi Parikh, MD, MPP, and Ezekiel Emanuel, MD, PhD, that concludes MA produces a 22% to 26% reduction in costs compared to MSSP (Medicare Shared Savings Program) arrangements. And this is across just a general patient population of all age ranges, if I’m reading the study right. The great results that are discussed in that JAMA article are what can happen when payers and providers align to tackle SDoH and preventative stuff and are willing to go out into the community to curb potentially avoidable downstream acute events.

David Carmouche, MD, by the way, on episode 343 talked at length about this. But there are variables here, and let me mention one of them: how good the Medicare Advantage plan is at risk-based contracting with physician groups. How good are they at putting patients into accountable relationships with provider organizations who are getting paid to keep patients healthy, meaning the MA plan is offering budget-based prospective payment contracts to physician groups? This is the case in that Ochsner/JAMA article example that Dr. David Carmouche was talking about. Ochsner, the health system in Louisiana, and MA plans were working together; and both assumed risk for this population.

Susan Dentzer, president and CEO over at America’s Physician Groups (APG), does a great job at covering a bunch of these topics on the Race to Value podcast.

Another thing that will impact care quality is how good the plan leadership is at balancing patient care and shareholder demand for profit.

Bottom line, it is not productive to be indiscriminately pie-eyed about pretty much anything in healthcare or throw babies out with bathwater on a regular basis. As Ge Bai, PhD, CPA, has said on this show (and others have said), there’s no angels and no devils in healthcare. Everybody is some combination of both. And, in general, the only reason anybody does anything in healthcare is because it appeals to their self-interest. So, not working with some other healthcare stakeholder because we perceive them as greedy or “industry” or whatever is gonna mean that nobody is working with anybody. Just keep your eyes wide open, check the math, and in your contracts, get actual dollar amounts and not discounts.

In this healthcare podcast, as mentioned a few times now, I am speaking with Betsy Seals. Betsy Seals is CEO and cofounder of Rebellis Group, a managed care consulting firm working with Medicare Advantage plans.

Oh, and one acronym alert before we dive in here: SNP stands for special needs plan. A special needs plan is a Medicare Advantage coordinated care plan that is specifically designed to provide targeted care and limit enrollment to special needs individuals. So, a special needs individual could be any one of the following:

1. An institutionalized individual
2. A dual eligible, meaning somebody who has Medicare and Medicaid
3. An individual with a severe or disabling chronic condition, as specified by CMS

SNPs are becoming a bit of thing in the MA space this year, and Betsy talks about this trend.

You can learn more at rebellisgroup.com.

Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience.

Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy’s expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations.

Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations.

Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs.

Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits.

06:16 Is Medicare Advantage still a cash cow?

06:42 Why should Medicare Advantage be the most lucrative line of business?

07:07 “If there weren’t a lot of money in it, nobody would do it.”

07:29 What should you know before jumping into the Medicare Advantage market?

14:04 What issues do upstarts overlook when getting into Medicare Advantage?

17:07 What is one of the next areas that Betsy thinks CMS will crack down on?

18:24 “Look at the data.”

19:53 “I think there’s a lot of lessons that you could see over the past years in the industry.”

20:52 “That’s what we see a lot of times is expansion without enough due diligence and thought put behind it.”

21:02 Why don’t common business models always work in healthcare businesses?

22:29 What are the new key trends coming out of the Medicare Advantage space?

26:04 Why is it important to bring in your clinicians when entering a dual market?

27:52 What’s going on in the chronic conditions space?

32:14 What’s necessary to the infrastructure with any kind of SNP product?

32:56 What’s Betsy’s forecast for the future of Medicare Advantage?

You can learn more at rebellisgroup.com.

@betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

Is Medicare Advantage still a cash cow? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

Why should Medicare Advantage be the most lucrative line of business? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

“If there weren’t a lot of money in it, nobody would do it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

What should you know before jumping into the Medicare Advantage market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

What issues do upstarts overlook when getting into Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

What is one of the next areas that Betsy thinks CMS will crack down on? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

“Look at the data.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

“I think there’s a lot of lessons that you could see over the past years in the industry.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

“That’s what we see a lot of times is expansion without enough due diligence and thought put behind it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

Why don’t common business models always work in healthcare businesses? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

What are the new key trends coming out of the Medicare Advantage space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

Why is it important to bring in your clinicians when entering a dual market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

What’s going on in the chronic conditions space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

What’s necessary to the infrastructure with any kind of SNP product? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

What’s Betsy’s forecast for the future of Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast

Recent past interviews:

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Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter