Leadership Health Care (LHC), a Nashville Health Care Council program for emerging leaders, Cohorts provide the participants an opportunity to engage in a peer mentoring program facilitated by an experienced healthcare executive. Throughout six cohort sessions, participants discuss substantive topics around a common focus area to enhance their knowledge and leadership skills.
Exploring Medicare Advantage and Managed Care with Lindsey Bussabarger at the LHC Managed Care Cohort
The Nashville Health Care Council’s Leadership Health Care (LHC) Managed Care Cohort recently gathered for an insightful discussion on Medicare Advantage with Lindsey Bussabarger, SVP, Insurance Controller, Trends Analytics & Forecasting at Humana. This session provided a deep dive into the complexities of managed care within Medicare, offering a look at how data-driven insights and financial trends impact the broader healthcare ecosystem.
Understanding Medicare Advantage and the Role of Managed Care
Medicare Advantage (MA) continues to gain traction as a preferred option for those eligible for Medicare, offering additional benefits beyond Original Medicare. Bussabarger shared valuable insights into how managed care plays a critical role in shaping the Medicare landscape, emphasizing the importance of financial sustainability and patient-focused care.
What is Medicare?
Medicare is a federal health insurance program for individuals who are aged 65 and older, under 65 with long-term disabilities, or diagnosed with End-Stage Renal Disease (ESRD). It is structured into different parts, each offering distinct coverage options. Part A provides inpatient hospital coverage, while Part B covers outpatient services like medical visits. Part C, also known as Medicare Advantage, offers an alternative to Original Medicare through private health plans, often including additional benefits like prescription drugs, dental, and vision. Part D provides prescription drug coverage, and Medicare Supplement offers additional coverage for Parts A and B.
What is Medicare Advantage?
Medicare Advantage (Part C) was created to help solve the cost and quality problem that was arising within Original Medicare. It allows private insurance companies to provide all the benefits covered by Original Medicare, often with added benefits such as dental, vision, and prescription drug coverage. Medicare Advantage is designed as a risk-based contract between private insurers and the government – plans are paid a fixed rate per member per month based on the estimated cost to cover that member. According to Bussabarger, “Medicare Advantage is a private alternative to Original Medicare. It’s not just about combining hospital and medical coverage, but adding benefits that people might need in their everyday lives.”
“Medicare Advantage is a private alternative to Original Medicare. It’s not just about combining hospital and medical coverage, but adding benefits that people might need in their everyday lives.” – Lindsey Bussabarger, SVP, Insurance Controller, Trends Analytics & Forecasting at Humana.
The Role of Managed Care in Medicare Advantage
Managed care is central to the Medicare Advantage model, as it ensures healthcare services are coordinated efficiently. Bussabarger explained, “Managed care helps ensure that patients get the right care at the right time. It’s not about restricting care, but about managing it in a way that benefits the patient and the system as a whole.” As healthcare costs continue to rise and the population ages, managed care offers an important strategy for addressing these challenges while improving care quality and outcomes.
“Managed care helps ensure that patients get the right care at the right time. It’s not about restricting care, but about managing it in a way that benefits the patient and the system as a whole.” – Lindsey Bussabarger, SVP, Insurance Controller, Trends Analytics & Forecasting at Humana.
Addressing the Need for Managed Care
With an aging population, the need for efficient, sustainable healthcare solutions is becoming even more urgent. Bussabarger highlighted the importance of leveraging data-driven insights to improve patient care. Data analytics can identify high-risk patients early, allowing for timely interventions that can prevent costly, avoidable hospitalizations.
The Financial Impact
Bussabarger presented key data that emphasizes the significance of managed care: it’s estimated that 10% of overall healthcare spending is potentially preventable. High-cost patients, who represent a significant portion of healthcare spending, experience at least one preventable encounter, with an average of $11.5K in potentially preventable spending annually. The financial impact of these preventable issues is staggering, with high-cost patients generating 20 times the potentially preventable spending compared to non-high-cost patients. These findings highlight the necessity of targeted interventions and proactive care management to reduce inefficiencies within the system.
Innovative Models for Managing Beneficiary Health
Bussabarger also shared how healthcare organizations are implementing innovative strategies to improve care delivery. One such strategy involves value-based care models, which reward providers for improving quality and patient outcomes rather than simply the volume of services provided. Additionally, advanced analytics are used to stratify patients based on their health needs, identifying rising-risk individuals who can benefit from earlier interventions. Multidisciplinary care teams are also central to these models, ensuring comprehensive, patient-centered care that addresses all aspects of a person’s health.
As plans contract with providers, they use a variety of payment models to incentivize proactive care. Bussabarger explained that value-based payment models incentivize providers to reduce the total cost of care and comprehensively address patient needs. One example is bundled payments, which offer a single, comprehensive payment that covers all services involved in a patient’s episode of care. Shared savings models encourage healthcare providers to coordinate care and share in any savings generated by improved efficiency. Full capitation is a more comprehensive model where providers take on responsibility for the total cost of care, including full downside risk.
Looking Ahead
The discussion reinforced the growing importance of Medicare Advantage and managed care in shaping the future of healthcare for seniors. As healthcare costs continue to rise and the needs of the patient population become more complex, strategic innovations will be critical in maintaining the sustainability and effectiveness of the system. Managed care is essential for improving outcomes and ensuring that the Medicare system can continue to serve seniors effectively for years to come.
The Next Generation of Healthcare Leaders
Leadership Health Care’s mission is to cultivate talented healthcare professionals into the industry leaders of tomorrow. LHC aims to provide young professionals with ongoing opportunities to develop their knowledge of the healthcare industry through educational events and networking opportunities. Fill out this form to learn more about LHC.