Healthcare Payers Need Agility and Flexibility to Implement Medicare Changes for 2015

Calvin Glenn
Digital Marketing Manager

Since the Affordable Care Act was passed in 2010, Medicare Advantage premiums have fallen by 10 percent and enrollment has increased by nearly 33 percent.  Today, enrollment in Medicare Advantage is approximately 15 million beneficiaries. Over half of these beneficiaries are enrolled in a four star or greater plan, which improves their access to care as well as the quality of care they receive.

Kathy McCarthy, Director of Sales Consulting for Oracle Health Insurance, discusses the topic in today’s post:

Many Changes Are in the Cards for Medicare Advantage Plans in 2015

The change in Stars ratings is significant. Plans receiving fewer than 4 stars will no longer be eligible for bonus payments.  Bonus payments for 4 and 5 star plans will be reduced. This can result in the loss of revenue for affected plans. Insurers need to look for new ways to reduce costs to account for the revenue shortfall. This can include anything from lowering administrative costs to improving quality of care.

Some other changes include:

  • Changes in payment models, capitation rates and reconciliation calculations
  • Changes to  out-of-pocket drug spending amounts
  • Improved notification for beneficiaries regarding changes in Medicare Advantage plan networks
  • Greater protection for beneficiaries:
    • Improved access to preferred cost-sharing
    • Improved coordination of care

Payers must act quickly and decisively to implement changes required to improve performance, whether boosting quality, outcomes, operational efficiency, or profitability. As such, healthcare payers should seek greater agility – including in their IT systems, which support modern enterprises. Specifically, they require the ability to quickly introduce new plans as well as support efforts to reduce operating costs and take advantage of emerging opportunities.

As a means to control TCO, healthcare payers are also looking to leverage engineered systems – solutions that combine hardware and software optimized to work together. In addition, many seek more open as well as scalable solutions that can cost effectively expand to meet changing requirements.

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