Delayed care will have a butterfly effect on the Medicare Advantage rate setting

• Many respondents to a recent survey about changes in consumer behavior during COVID-19 report delaying care, including 63% of individuals with chronic conditions and 53% of seniors.
• To reassure patients, it is important providers communicate with patients that they should come to the hospital if they need emergent care and that the healthcare organization has taken every step to provide quality care in a safe environment.
• It is important for someone from their provider’s care team to reengage with high-risk patients, address gaps in care plans and schedule other medically necessary services.

Given consumer concerns about contracting COVID-19 in a healthcare setting, coupled with the economic downturn, many respondents to a recent survey about changes in consumer behavior during COVID-19 report delaying care.

Most concerning, 63% of individuals with chronic conditions and 53% of seniors responding to the Alliance of Community Health Plans’ (ACHP) survey report delaying care. And overall, 38% of individuals report that they will continue to delay care.

Takeaway

First, providers should reassure the public that it is safe to engage with the “brick-and-mortar” healthcare delivery system by letting consumers know:

• If they need emergent care, they should come to the hospital
• That the provider has taken every possible step to ensure that it can deliver high-quality care in a safe environment

Second, particularly for high-risk patients, it will be important for someone from their provider’s care team — ideally an existing care coordinator if one is assigned — to reengage with the patient, address gaps in care plans and schedule other medically necessary services. HFMA is hearing anecdotally from members that they are starting to see sicker non-COVID-19 patients present in the ED, and more often than not these patients are being admitted for conditions that could/should have been managed in the ambulatory setting had the patient not delayed care.

Beyond the impact on immediate utilization, postponed/avoided care will have a range of downstream impacts, particularly on risk adjustment and Medicare Advantage pricing for plan year 2021. Diagnoses recorded in 2020 are included, in part, in the 2021 risk scores. While CMS is allowing MA plans to incorporate diagnoses captured under certain circumstances during telehealth visits, plans and providers will need to ensure they have processes in place to capture and submit this data. Otherwise, MA plans will receive lower capitated payments, which do not reflect (or accurately compensate them for) the burden of disease carried by their Medicare enrollees.

Fewer visits will also have an impact on the number of $0 plans and plans with supplemental benefits available. An Avalere Analysis of COVID-19 Impact on Medicare Advantage Risk Scores for AHIP estimates that if nine months of 2018 claims data were used instead of 12 months of claims data, risk scores would be lower by 6.5%. This assumes, conservatively, that utilization is only impacted by three months for COVID-19. The Avalere analysis estimates that all things being equal, a 4% decrease in HCC scores would require all Medicare Advantage Prescription Drug plans to charge a premium in 2021, or plans offering supplemental benefits would need to decrease the amount of supplemental benefit by 24%.