Innovation in Medicare Advantage Begins With Doctors

When we think of healthcare innovators, we often think of technology entrepreneurs, researchers finding cures for rare diseases, or top surgeons. We rarely think of primary care physicians. But throughout my career, I’ve found that primary care physicians must innovate on an almost daily basis. We see some of the most challenging patients—my practice serves low-income seniors who are managing multiple complex chronic conditions—and we serve as the first entry point into the healthcare system for most patients. It’s a tremendous responsibility, and one that doesn’t work without innovation.

One of my patients, for example, came to me after multiple hospitalizations over the previous 5 years. He was on a path toward hospice care, and for him and his family, the situation seemed hopeless. After working with his entire care team to develop a plan, review his medication, and address each of his conditions, we were able to keep him out of the hospital the following year. And the years after that. Doing this required an entirely new way of thinking about his treatment plan and care.

Last month, CMS gathered new ideas from individuals and organizations for the Center for Medicare and Medicaid Innovation (CMMI). CMS called for ideas on a broad range of topics, from payment models to innovation in mental and behavioral health delivery. At ChenMed, we were pleased to see Medicare Advantage among these topics—we believe there is no program that helps provide more innovative care for seniors. In fact, we believe Medicare Advantage has the power to transform care for the neediest patients with proven, value-based care strategies.

The CMS request, however, primarily focused on innovation from health plans and hospitals. To drive real innovation in Medicare Advantage—improvements that will result in better health outcomes and reduce costs—CMS should start with doctors.

Through Medicare Advantage, my practice, ChenMed, is able to provide better care and better health outcomes. We are paid up front per patient and are responsible for the total cost of care. That means physicians stay focused on getting patients healthy and keeping them that way. We can truly invest in our patients early and often—with preventative care, chronic disease management, and courtesy services. In addition, our physicians are able to have smaller patient panels—about 450 per physician, rather than the national average of 2300.

All of this results in our physicians investing more face-to-face time with patients—189 minutes with each patient annually, compared to the national average of 20.9 minutes. This additional time allows us to make earlier diagnoses and more timely interventions. As a result, we see a notable difference in our patient outcomes. In 2015, our rates of ER visits were 33.6 percent lower than the average among all Medicare beneficiaries in the counties in which we operate. Our patients averaged 28 percent fewer hospital admissions and 25.7 fewer in-patient hospital days than average.

We believe that CMS can strengthen Medicare Advantage with innovations that will allow physicians working in similar risk-bearing models to achieve even larger improvements in outcomes and cost-savings. We recommend 2 specific improvements to remove barriers to innovation for more providers.

First, we can allow providers to waive copays. Many of the seniors we serve are on fixed incomes and cannot afford copays for testing or office visits. When they are concerned about costs, they do not call or see us as often, preventing us from providing the best care possible that will keep them healthy and prevent more serious health problems in the future. Enabling us to waive their copays would remove a barrier to care, allowing us to see them more and improve their health outcomes.

Second, we can ensure that payment amounts for patient care and the timing of those payments accurately reflect the patient population, including accounting for social determinants that may affect health outcomes. That helps providers who take full risk have the necessary resources to fully address the health needs of challenging patient populations. For example, a patient who is managing diabetes and living in a food desert will have greater challenges than one who lives near supermarkets with healthy food options.

By spending time with patients, primary care physicians have the opportunity to get a full picture of the patient’s health, including outside factors that influence it. In particular, providers in value-based care models, who are responsible for the total cost of care for their patients, have every incentive and more flexibility than most insurers to offer services and programs that lead to better care and lower costs. CMS should remove any barriers standing in their way.