In this article the NYTimes writes that the US is aging rapidly and needs to prepare for the social and economic consequences, including potential labor shortages, strain on social programs, and the need for more elder care.

KFF Health News and The New York Times examine how the immense financial costs of long-term care drain older Americans and their families.

Nicholas Kristof argues that the U.S. has a healthcare crisis despite advanced technology, and improving health requires addressing access, behavior, and social determinants.

Key Points

• Poor health outcomes in the US compared to other wealthy nations, despite advanced medical technology. (e.g. avoidable diabetic amputations)
• Contributing factors: lack of healthcare access, unhealthy behaviors, social determinants of health (poverty, education).
• Solutions: expand healthcare access, promote healthy behaviors, address social determinants of health (e.g. Delta Health Alliance program).

John Oliver explains the industry behind nursing homes and assisted living facilities, and why long-term care needs fixing.

Key Points

• Failing Nursing Home Industry: The nursing home industry is failing to provide adequate care for its residents. This is caused by understaffing, low wages for nursing assistants, and a focus on profit over quality care. Residents are often neglected and may even be subjected to unnecessary medical treatments.
• Problematic Assisted Living Facilities (ALFs): Assisted living facilities (ALFs) are a less regulated alternative to nursing homes, but they also have problems. Many ALFs are not equipped to care for dementia patients, and there have been cases of residents being neglected or even abused.
• Need for Home-Based Care: There is a growing need for home-based care for the elderly and disabled. This would allow people to stay in their homes for as long as possible, but it requires reform at the national level to make it a viable option for more people.

People over 60 are more likely to live alone in the United States and Europe than in other regions of the world.

Daniel Kaplan writes how senior living and healthcare are merging, affordability remains a major challenge, and new care models are emerging to address these issues.

Key Points

• Merging of Senior Living and Healthcare: Senior living facilities are increasingly providing healthcare services due to the rising acuity of residents. This trend is expected to continue as the population ages.
• Affordability Crisis: The article highlights the challenge of many seniors not being able to afford assisted living, nursing homes, or even basic care. This is a major issue that needs solutions.
• New Care Models: The emergence of new models like disease-specific care and wrap-around care models offer promise for improving the quality of care for seniors while potentially reducing costs.

The pandemic played a role in increased consumption, but alcohol use among people 65 and older was climbing even before 2020.

Dr. Eric Bricker highlights that while Medicare beneficiaries enjoy high satisfaction with their healthcare plans, the program faces financial challenges.

Key Points

• High Satisfaction among Medicare Beneficiaries: Dr. Bricker highlights a study showing that over 90% of seniors are happy with their Medicare plans. It emphasizes the ease of access to specialists and short waiting times for appointments.
• Traditional Medicare vs. Medicare Advantage:
  • Traditional Medicare: Offers more freedom in choosing doctors but may have higher out-of-pocket costs.
  • Medicare Advantage Plans: Typically have lower out-of-pocket costs but require referrals from a primary care physician and may limit choice of doctors.
• Uncertainty about Medicare Funding: While Medicare provides excellent benefits, the Dr. Bricker warns that the program faces financial challenges. The Medicare Part A trust fund that pays for hospital care is projected to become insolvent in 2026 [more recenlty this date has been moved to 2036].

Read how Medicare patients try to understand the complex Medicare system.

The Center for Medicare and Medicaid Innovation offers four primary care models to incentivize quality care delivery, with a focus on expanding access and rewarding value-based practices (Center for Medicare and Medicaid Innovation).

Key Points

• ACO Primary Care Flex Model (ACO PC Flex)
  • Provides upfront and monthly payments to ACOs for better care delivery.
  • Focuses on expanding access, improving care approaches, and reducing health outcome disparities.
• Making Care Primary (MCP)
  • Offers three tracks for practices to enter value-based payment arrangements.
  • Aims to improve access to coordinated and accountable primary care, particularly for underserved practices.
• Primary Care First (PCF)
  • Shifts payment structure from fee-for-service to prospective payments with performance bonuses.
  • Focuses on providing flexibility for innovative care delivery based on patient needs.
• ACO Realizing Equity, Access, and Community Health (ACO REACH)
  • Aims to promote health equity, provider leadership, and serve underserved communities.
  • Offers two risk-sharing options with financial incentives for ACOs.

The KFF explains that the Medicare Hospital Insurance trust fund is projected to be depleted by 2028 [more recenlty this date has been moved to 2036], raising concerns about future program financing.

Key Points

• Medicare Part A Trust Fund Nearing Depletion: The Hospital Insurance (HI) trust fund, financing Medicare Part A benefits, is projected to be depleted by 2028. This doesn't mean Medicare ceases to operate, but there will be a shortfall between spending and incoming revenue.
• Factors Affecting Solvency: Several factors affect HI trust fund solvency, including economic growth, healthcare spending trends, and demographics (aging population). Recent economic changes due to the pandemic have impacted projections, highlighting the sensitivity of the depletion date.
• Long-Term Outlook: Medicare faces financial pressures due to rising healthcare costs and an aging population. Long-term solutions may involve reducing payments to providers, modifying benefits, or increasing revenue through tax hikes.

In a study by Patterson et al., high coverage of drugs selected for Medicare price negotiation was observed in 2019 and 2023, but concerns remain about potential limitations on future access due to utilization management practices.

Key Points

• The Inflation Reduction Act created a program to negotiate prices for certain Medicare drugs and requires coverage by Medicare plans upon a fair price agreement.
• Concerns exist regarding potential limitations on patient access to these drugs despite mandated coverage. These limitations could include prior authorization requirements or placement on higher cost tiers by insurance companies.
• The study investigates coverage of these drugs in 2019 and 2023 to assess pre-negotiation program accessibility and establish a benchmark for future monitoring.

Ben Schwartz argues that while Medicare Advantage offers benefits, it has limitations, and explores how a different model, Making Care Primary (MCP), could address those limitations by improving care coordination and potentially offering more integrated specialist care.

Key Points

• Medicare Advantage Limitations: Despite its supposed benefits like capitation and value-based care, has limitations. These limitations include potential overpayments, cherry-picking healthy patients, and squeezing specialists with lower pay.
• "Making Care Primary" (MCP) as an Improvement: MCP is a potential improvement over MA. MCP focuses on better coordination between primary and specialist care and creates a pathway for integrating specialist care within advanced primary care models.
• Potential of MCP: MCP could address specialist care limitations by creating incentives for Advanced Primary Care (APC) practices to manage specialist care in-house. This could involve hiring specialists, partnering with next-generation specialists, or developing microcenters focused on specific conditions.

Dr. Chris Chen spokes about ChenMed's model of medicine is a pure value-based care model.

Key Points

• ChenMed's care model focuses on value-based care for high-risk populations, targeting Medicare Advantage patients and taking full capitation to reduce hospitalization rates and improve outcomes.
• Traditional fee-for-service healthcare incentivizes volume over value, rewarding doctors for seeing more patients and performing more procedures, not better outcomes, and disincentivizes preventative care.
• Large healthcare systems are slow to adopt disruptive innovations like ChenMed's model due to volume incentives and established systems. Chen Med fills a market gap by offering a more patient-centered approach.

Navigating the complex elder care landscape requires thorough research, targeted problem identification, and a willingness to adapt and pivot in order to develop a solution with a sustainable competitive advantage.

Key Points

• Mega trends are a starting point, not a solution: While mega trends (like the aging population) indicate large-scale problems, they don't automatically translate to a viable business. Entrepreneurs must go beyond the obvious and identify specific pain points within the trend where they can develop a unique solution.
• Thorough research is essential for finding your niche: Extensive research, including secondary sources, expert interviews, and user feedback, is crucial for uncovering hidden opportunities and understanding the competitive landscape. This knowledge is essential for developing a product or service that truly addresses unmet needs.
• Pivot and iterate to find your competitive advantage: Even with solid research, the path to success isn't always linear. Being willing to pivot and iterate based on user feedback and market changes is crucial to finding a product-market fit that offers a unique value proposition and a sustainable competitive advantage. Sometimes, recognizing when an idea lacks a clear path to a competitive edge, as Yoskovitz did, is the most strategic decision.

Alex Wess, published in The Pulse by Wharton Digital Health, chats with Dr. Farzad Mostashari about how Aledade believes independent primary care physicians are best positioned to benefit from value-based care.

Key Points

• Focus on Independent Primary Care: Aledade partners with existing independent primary care practices to help them transition to value-based care. They believe independent practices have the most to gain from value-based care because they influence a large portion of healthcare costs while accounting for a small percentage themselves.
• Technology and Evidence-Based Approach: Aledade uses a technology platform and data analysis to guide practice workflows and implement interventions to reduce healthcare costs and improve outcomes. They heavily rely on evidence-based practices and constantly test new interventions before large-scale implementation.
• Profitability and Growth: Aledade is one of the rare profitable healthcare tech companies. They recently raised $123 million to invest in new interventions and expand their platform. They prioritize long-term success and mission over an IPO and are in a good position to choose when and if to go public.

KFF writes how Medicare Advantage plans are facing growing criticism from hospitals and doctors due to claim denials, preapproval hassles, and low reimbursement rates, leading to new regulations and potentially impacting patient choice.

Key Points

• Hospitals and doctors are voicing frustrations with Medicare Advantage plans. They cite claim denials, burdensome preapproval processes, and inadequate reimbursement rates. This frustration is leading some providers to stop accepting certain Medicare Advantage plans.
• The Biden administration is taking action to address these concerns. New regulations aim to restrict prior authorization requirements and improve access to necessary care for patients.
• Increased scrutiny surrounds Medicare Advantage plans, coming from both healthcare providers and lawmakers. This scrutiny is expected to persist as the federal government implements new regulations.

On Thursday, March 16, 2023, KFF hosted an hour-long web briefing focused on Medicare Advantage and some of the policy challenges.

Key Points

• Debate over how much Medicare pays Medicare Advantage plans: The federal government pays Medicare Advantage plans a fixed amount per beneficiary each month. There is disagreement about whether these payments are too high, with some arguing that Medicare Advantage plans are getting paid more than they should for the people they cover.
• Risk adjustment and coding: A key factor in how much Medicare Advantage plans are paid is a system called risk adjustment. This system takes into account the health status of enrollees, so that plans are paid more for sicker patients and less for healthier patients. Some argue that Medicare Advantage plans are reporting more diagnoses for their enrollees than traditional Medicare, which inflates their risk scores and leads to higher payments.
• Potential impact of proposed changes to payment system: The Biden Administration has proposed changes to the way Medicare Advantage plans are paid. These changes could reduce payments to plans by 3%. However, the impact on beneficiaries is uncertain. Some argue that plans will reduce benefits or increase premiums, while others argue that they will absorb the changes.

In this article Phil Galewitz and Holly K. Hacker discusses the debate surrounding how much Medicare pays Medicare Advantage plans, including the risk adjustment system and potential effects of proposed payment changes.

Key Points

• CCM Benefits: The Chronic Care Management program provides personalized care, regular touchpoints with healthcare providers, and coordinated care to Medicare enrollees with chronic conditions. This program helps keep patients out of the hospital and reduces unnecessary visits, potentially improving health outcomes.
• Sluggish Participation: Despite clear benefits, enrollment in the CCM program remains low. This is due to a variety of factors including the opt-in requirement for both patients and doctors, capacity limits for some medical practices, and the bureaucratic burdens of documentation and billing.
• Outsourcing Solutions & Financial Incentives: Some medical practices outsource CCM services to companies, while others manage it in-house. The program offers additional income for providers, with Medicare paying an average of $62 per patient, per month, for the service. However, concerns exist about potentially unnecessary CCM enrollment for patients who don't fully need the service.

A podcast to demystify healthcare and Medicare for senior-serving professionals and providers.

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