Product innovation: Medicare
The challenge
Broad provider networks. Low premiums and co-pays. Added benefits beyond traditional Medicare. These are ways that private payers have differentiated their Medicare Advantage plans from public and private competitors. Medicare Advantage plans attractive to enrollees yet profitable for payers have been enabled partly by generous government funding. Too generous, according to some studies and political critics. Congress is targeting Medicare Advantage for payment cuts, citing the additional cost - 12 percent more for each enrollee, on average, than original Medicare - as an extravagance whose main beneficiaries are insurers. The federal government has already been cutting funding for Medicare Advantage plans - a trend almost certain to continue. Regulatory scrutiny and compliance enforcement are also increasing. Payer margins are shrinking. Risks are rising. In the near future, reduced funding may make government-sponsored Medicare plans competitive with private plans.
To keep your Medicare Advantage plans competitive despite funding cutbacks, you will need to better manage your costs. Administer your plans more efficiently. Offer value through broader provider networks and innovative combinations of benefits. Assess and mitigate risks. Adopt best practices to give your members the right care in the right setting at the right time.
Keeping current with requirements from the Centers for Medicare and Medicaid Services (CMS) in addition to keeping products innovative and cost competitive present formidable administrative and strategic challenges for insurers.
How we can help you
Maintaining value-based differentiation of your Medicare Advantage plans will be more difficult with reduced funding and increased compliance enforcement. Designing and implementing your Medicare Advantage and Part D plans require special care so they are profitable, compliant and valuable to your members. Our cross-functional teams bring together professionals with experience in public and private sectors who understand the stringent and complex regulations that govern how you need to design and implement your Medicare Advantage and Part D plans. You need to acquire the resources and expertise to manage the risks and administrative complexities of Medicare and align your plans with your organization's business strategy. We can help you with benefit design and pricing, strategic planning, preparation of applications and competitive bids, sales and marketing analysis, plan implementation, network development and medical management.
You should choose your pharmacy benefit managers (PBMs) carefully and monitor their transactions for compliance and integrity. We can help you with Part D vendor oversight and accurate tracking and submission of transactions. Improved management in these areas can avoid severe financial consequences in the form of sanctions, fines and repayments.
Common services include:
- Assessing, designing, constructing and implementing Medicare Advantage and Part D processes to improve operational performance
- Assessing and mitigating risks
- Evaluating compliance with Medicare Advantage and Part D regulatory requirements
- Designing short- and long-term strategies for Medicare Advantage and Part D lines of business
