Becker's ASC Review

27 HEALTHCARE NEWS 27 How health systems can 'close the gap' in Medicare Advantage By Alan Condon A s a leader who has navigated both sides of the healthcare equation — payer and provider — Prime Healthcare CFO Steve Aleman brings a unique perspective to one of the most pressing challenges facing health systems today: closing the reimbursement gap in Medicare Advantage. Mr. Aleman recently joined the Becker's Healthcare podcast to discuss how health systems can adopt proactive strategies, robust systems and strong payer relationships to overcome challenges and unlock growth opportunities within Medicare Advantage. Editor's note: This is an excerpt from the Becker's Healthcare podcast. Responses were lightly edited for clarity and length. Question: What trends are you paying most attention to as a health system CFO? Steve Aleman: One key trend is the growing prevalence of Medicare Advantage programs, which now cover more than half of all Medicare beneficiaries. While many believe MA ultimately lowers costs, the fact is that it poses serious challenges to hospitals. Prior authorization denial rates are unquestionably high, which causes providers to absorb additional costs to refile a claim and adds uncertainty around how much we will be paid or, for that matter, if we're paid at all. Claim denials increase costs and create changes to defining the expected net reimbursement. It is imperative to be extremely active in engaging with MA plans to ensure we have state-of-the-art information in those discussions to close the gap between what we are reimbursed for providing care and the actual cost associated with providing that care. Q: The challenges associated with MA are many, but where do you see the biggest opportunities within the program, and how can health systems unlock them? SA: I previously was on the payer side, but earlier in my career I served as CFO for an organization that included both hospital providers and medical groups while managing capitation and relationships with hospitals. So, I've experienced firsthand the push and pull of the differing incentives between these entities. At the end of the day, when dealing with authorizations and the structure of contracts, direct interaction is crucial. You need robust systems, processes, and protocols in place to prevent missteps that could lead to denials. So, when it does reach the appeal stage, it should ideally be a straightforward, black-and-white issue, allowing you to address it in real-time and get the claim paid. Solid documentation and protocols are essential. At Prime, we've historically been very proactive in working with MA plans to ensure claims are paid. Whether it involves litigation or settlements, having comprehensive documentation and efficient systems makes all the difference. While it's a lot of work to get to that point, the importance of these measures has never been more important. n Every member of the executive team is thinking about capacity and expanding access to care. Shelly Schorer, CFO of the California Division for Chicago- based CommonSpirit Health, said her top priority for improving patient access to care in the next two to three years is expanding access through extended hours and adding clinicians as well as urgent care sites to the network. "It is also imperative that we maintain a continued focus on safety and quality by actively participating in high reliability programs to drive improvements and enhance patient outcomes," she said. Children's and specialty hospitals are feeling the pinch as well. Despite serving a narrow patient population, they're seeing increased volumes. "Demand for pediatric specialty services continues to grow, yet capacity limitations and barriers persist," said Ben Goodstein, vice president and chief ambulatory officer of Dayton (Ohio) Children's Hospital. "We are actively addressing these challenges by optimizing scheduling processes, expanding provider capacity and exploring partnerships to reduce wait times and increase service availability, ensuring timely care for the children who need us most." Health systems already overburdened by patient volume have reason to act quickly; Sg2, a Vizient company, projects hospital inpatient utilization days will increase 9% in the next 10 years, and outpatient volumes are expected to jump 15% as well. Health systems with a successful approach will engender trust in the community, while those that fail risk frustrating patients, losing their loyalty and stymying long-term growth. "To harness these trends, healthcare leaders must look deeper and shi from transactional growth to create access that delivers a compelling, value-driven experience for patients," according to the Vizient report. "is means developing access points that prioritize convenience, meet the needs of different segments in an individualized way, encourage engagement and build lasting trust." e report notes typical systems capture less than half of patients' total healthcare spend, while loyal patients spending 75% or more of their dollars with a single system generate more than three times the revenue of an uncommitted one. e Vizient report underscores the importance of loyal patient growth with a simple equation: for a $2 billion system, increasing the number of loyal patients by 1% means $40 million revenue jump. "e key to maximizing access and care is to look at your overall lifetime relationship with the patient and prioritize what interactions and populations you should target to create the highest impact and value possible for them – and then steer away from those interactions that fall short," said Yelena Bouaziz, principal of intelligence at Vizient. n

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