Doing More with Less: Scalable Strategies for Medicare Advantage Plans in an Evolving Healthcare Landscape
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AI and Peer Engagement: Enhancing Member Experience and Retention
MA plans are leveraging artificial intelligence (AI) tools and peer support models to engage members at scale without raising labor costs.
- AI Virtual Assistants reduce phone wait times, provide personalized plan information, and encourage telehealth use. UnitedHealthcare’s AI-based “Agent Virtual Assistant” system, for example, helps call center representatives instantly access claim records and address member needs in seconds. According to Humana, these technologies can deflect high-cost in-person visits by promoting more efficient care settings.
- Peer-to-peer programs build trust and drive better outcomes, especially for vulnerable members. Wider Circle’s community circles, supported by Milliman data, showed 50% lower disenrollment and $103 per member per month in net savings among engaged MA members. According to McKinsey & Company, social connection efforts can help reduce isolation, emergency visits, and overall utilization.
Key Takeaway
AI-enabled customer service plus peer-led social engagement can simultaneously boost satisfaction and lower avoidable costs. With member experience measures now comprising up to 57% of Star Ratings, enhancing service and retention has become critical.
Preventive Care & Chronic Disease Management: Cost-Effectiveness Through Digital Engagement
Preventive measures and chronic condition support are cornerstones of MA’s value-based approach.
- Telehealth & Remote Monitoring: During the COVID-19 era, telehealth usage among Medicare beneficiaries skyrocketed, rising from 7% pre-pandemic to about 47% in Q2 2020. Humana reports a 7% reduction in hospital admissions and 12% fewer ER visits among telehealth users in its value-based contracts.
- Medication Adherence Programs: According to McKinsey & Company, industry studies suggest that up to $300 billion in avoidable medical spending is attributed to poor adherence. AI-based prompts, refill reminders, and mobile apps have reduced non-adherence by 10–15% in pilot programs, leading to fewer acute events for Humana.
Key Takeaway
By integrating telehealth and digital reminders, MA plans can close care gaps early, cutting high-cost admissions and improving Star Ratings. Plans can capture additional quality bonuses by showing improved outcomes and member adherence.
Addressing SDOH: Improving Equity and Engagement at Scale
Social determinants like food insecurity, housing instability, and digital literacy strongly affect member health.
- Digital Inclusion: A lack of digital skills can limit telehealth adoption and patient portal use. CareFirst BlueCross BlueShield launched a digital literacy pilot for older adults, leading to higher telehealth usage among previously disconnected members.
- Community-Based Partnerships: Anthem’s $87.9 million investment in housing initiatives aims to address the root causes of poor health. SCAN Health Plan launched a “Friendly Phoner” program to reduce loneliness and increase adherence to preventive screenings.
Key Takeaway
Investing in SDOH solutions reduces downstream costs from unmanaged conditions and supports CMS’s health equity goals. Meeting the forthcoming Health Equity Index benchmarks can also boost Star Ratings.
Aligning with CMS Regulations and Star Ratings
Regulatory changes increasingly reward innovation and equity:
- Star Ratings Emphasize Experience & Equity: Up to 57% of Star Ratings are tied to patient experience and access. Plans with strong digital and community outreach typically do better in CAHPS surveys.
- Health Equity Incentives: CMS introduced a Health Equity Index, offering bonus points for plans closing disparity gaps. AI and SDOH programs can demonstrate equitable outcomes for underserved members.
Key Takeaway
By proactively adopting AI, prevention-focused digital tools, and SDOH solutions, MA plans can stay ahead of regulatory shifts, earn higher Star Ratings, and secure bonus payments.
A Roadmap for MA Innovation
Medicare Advantage plans can do more with less by blending AI-driven support, preventive telehealth, and SDOH initiatives. Early adopters such as Humana have shown reduced ER visits, higher medication adherence, and improved Star Ratings. As CMS continues to reward quality, experience, and equity, these strategies position MA plans to deliver better outcomes, enhance member loyalty, and control costs in a dynamic healthcare market.
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