Medicare Advantage Stakes
[00:00:00] Stacey Richter: Episode 510. The Impact on You of Medicare Advantage Goings on—2026 Edition. Today I am speaking with Betsy Seals.
[00:00:29] Stacey Richter: I came up with at least one way to tell the difference between making a fair profit and profiteering. If someone makes more money when the patients or members they serve are worse off, yeah, call that profiteering.
For more on what is fair profit versus what is profiteering, I would recommend you go back and listen to the episodes on Mission and Margin with Dr. Ben Schwartz (EP481) and then with Dr. Mick Connors (EP495) But it's probably not an accident that I have started an episode about Medicare Advantage in this fashion.
To this end, I am very much looking forward to hearing what's up with Medicare Advantage from the one and only Betsy Seals, who is back for her third appearance on Relentless Health Value.
And her advice in a nutshell is this, don't profiteer. There are ample ways to make a fair profit. Just go back to basics and do it the right way. I wanna kind of tick through the list of things that I think about when I think about Medicare Advantage and just how it is relevant to absolutely everybody.
The first thing I think about when I think about Medicare Advantage, and this is very obvious, is what Medicare Advantage plans do or don't do, are our tax dollars at work or not at work as the case may be.
Along these same lines. The second thing, how does this impact our elders, our family, our friends, our grandparents? These are our senior citizens, getting the care or not getting the care that they may need. Those two are obvious.
Cost Shifting To Employers
[00:02:01] Stacey Richter: Now let's talk about a few less obvious things. Here's the third point that I think about as I listen to conversations about Medicare Advantage. Cost shifting, right?
It is a well-known fact how big vertically integrated carriers, and when I say big vertically integrated carriers, I mean ones that have a Medicare Advantage line of business. When negotiating with big consolidated health systems, the release valve of those negotiations is commercial rates. These are the rates that the self-insured employers are paying.
So the carrier says, “Look, gimme the best Medicare Advantage rates. I want the best Medicare Advantage rates because I, the carrier, am paying for those.”
Savings from those lower rates accrues to the Medicare Advantage plan and its shareholders or investors or executives, right? So the carrier with the Medicare Advantage plan is like, “Look, go as low as we can go on the Medicare advantage rates, but it's okay, health system, if you make up the difference with the ASO commercial book of business.”
Because right, ASO means administrative services only. It's not the carrier who's paying those commercial rates at the ends of the day. So the carrier uses its full book of business to negotiate lower rates for itself while at the same time cost shifting to commercial members.
In fact, there was some research that was cited. It was episode 436 with Elizabeth Mitchell and I quoted Luke Prettol. But there was research that puts this markup at 4.7% above what employers would otherwise pay if they had an ASO that did not have a Medicare Advantage Plan.
[00:04:12] Stacey Richter: So yeah, number 3, big thing that I think about when listening to MA insights, like the ones that Betsy drops today, I think about will this accelerate or ameliorate, or really have anything to do with what is going on around those negotiating tables with ASOs and health systems. Because let's not forget health systems account for about 50% of most self-insured employers, total health spend.
Vertical Integration Risks
[00:04:32] Stacey Richter: The fourth thing that I think about will MA carriers underpay independent practices, especially primary care practices, will it pay indies less? And then if it pays 'em a lot less, would ultimately manage to put them out of business. Ultimately raising the total cost of care for everybody.
But if we're thinking about this strictly from Medicare Advantage financial perspective, a really great move here, these are big, vertically integrated companies, don't forget. Many of them own provider organizations. This is why the FTC tends to frown on vertical integration.
So will these Medicare Advantage organizations who own provider organizations pay the provider organizations they own more.
By the way, it's the same thing that's going on on the pharmacy side of the house when a PBM pays pharmacies that they own more. I will link in the show notes to a LinkedIn post by Stanley Warren about this topic.
And there are a lot of obvious, maybe less obvious reasons for why paying providers the carrier itself owns more is a great short-term move. One of them is Intracompany eliminations. Listen to the episode with Preston Alexander.
But here's another reason, rate increases paid by the government for Medicare Advantage plans are based on fee-for-service benchmarks. So if fee-for-service rates go up, then the Medicare Advantage plans can negotiate more money for themselves. If the MA plans own the providers that are charging said FFS rates, then this is, I don't know, a great strategy. Especially given the lobbying budget that some of these entities have.
So look, on today's show, I get the distinct opportunity to speak with Betsy Seals. My guest today, as I mentioned earlier, and we go through her advice for MA plans and what they need to get busy with and ensure, make a fair profit, go back to basics and do it the right way.
That's her bottom line advice. Don't be putting your hands in the cookie jar. Sooner or later you're gonna get caught. Focus on the members that you're really good at serving. And lastly, when it comes to STARS or other quality measures, lift them the right way, like actually through better member health and actually better member experience, not some engineered mechanism by which one can check a box that honestly doesn't deserve to get checked.
Because now we're back to the beginning and you're gonna get caught with your hand in the cookie jar and it's profiteering. Let's just get real about that. If somebody's checking boxes that they don't deserve to check, member health is not improving.
Meet Betsy Seals
[00:07:11] Stacey Richter: Betsy Seals my guest today, as I have said at least three times, co-founded Rebellis Group, which is a Medicare Advantage consultancy. She became CEO of its parent company, Alerion Advisors. Now she is a board member and also she works with startups in our industry.
My name is Stacey Richter, and this podcast is sponsored by Aventria Health Group with an assist today from Payerset to help us with the financial support that we need to stay on the air.
And with that, here is my conversation with Betsy Seals.
Betsy Seals, welcome to Relentless Health Value.
[00:07:43] Betsy Seals: Thank you for having me.
State Of Medicare Advantage
[00:07:44] Stacey Richter: We are recording this at the beginning of the second quarter in 2026. What's sort of the state of the state if we're thinking about Medicare Advantage plans?
[00:07:53] Betsy Seals: So when I'm looking back over the last, let's say, five or six years, starting with COVID pandemic. And then looking back even further from that, what we see in Medicare Advantage is cycles. And where we are in the cycle right now is that it's kind of a stabilization, um, and retraction for a lot of MA players.
We've seen a lot of those large players exit certain markets. We've seen smaller players completely exit Medicare Advantage. We've had some regulatory shifts. Obviously we've had an administration shift, which always trickles down to the program as well. And what we're seeing is that it's a hard time to really thrive certainly, but even survive in Medicare Advantage.
So a lot of these national players and even regional players are proceeding with caution, not making a lot of big moves, and really planning for stability versus high growth during this time, or kind of seeing the program in a stabilization time period.
[00:08:49] Stacey Richter: Yeah, I just saw an article actually in Stat News bolstered actually by something that Eric Bricker wrote that showed that the growth of Medicare Advantage, I think, was negative 1.2%. Some of it at least had to do with the fact that usually insurers make an underwriting profit in the first three quarters of a calendar year, and then the last part of the year when everybody hits their deductibles is when they, they take a loss.
This year, they actually had an underwriting loss in the first three quarters indicative of they made some assumptions and priced premiums too low.
Benefits Pullback Impact
[00:09:22] Stacey Richter: At the end of the day though, does that impact patients? You know, you can jigger things around so that patient care ultimately isn't impacted or like what happens here.
[00:09:32] Betsy Seals: Medicare Advantage, it's a whole ecosystem. My easy answer to the question is that it does matter, and we have seen that in the richness of the benefits over certainly this year and last year as well. We started to see some of those really competitive, we'll use the word competitive supplemental benefit offerings, pull back, and we saw that for a reason.
We saw that because the program was increasingly unstable and there were a lot of losses for a lot of the, especially publicly traded companies that were public knowledge. I would say that it does impact the beneficiary.
Now, it all depends on how that plan handles those losses or those, you know, projections. Because if we're really focusing on quality of care, we're taking back some of those flashy benefits that might only be used for enrollment capture and focusing benefits on outcomes and quality of care. Then I think that the impact to the beneficiary could be less, but that's a plan by plan decision. Right?
[[00:10:30] Stacey Richter: To just restate what Betsy said, which I probably should have restated in the episode, but I did not, she basically said that some of the, as she calls them flashy benefits, were less about patient health and more in a way marketing to drive enrollment into the plan.
So if all the carrier did was remove some of what might be considered perks for marketing, but left the stuff that actually really impacted outcomes and quality of care, then yeah, cuts could be made without negatively really impacting patient outcomes.]]
Back To Basics Strategy
[00:11:10] Stacey Richter: So if I'm thinking about this like a plan, who is trying to figure out how to do right by patients, I'm gonna ask you for some specifics, but is there some sort of like underlying strategic through line here that should be considered?
[00:11:27] Betsy Seals: Yeah. You know what I've seen over the decades that I've been in Medicare Advantage is that a lot of decisions are made based on finances.
Let's be real, right? STARS decisions made on checking a box so that that bonus payment can be received. Benefit, PBP designs, planned benefit designs made by the same criteria. And so really what we have seen be successful for the long run is not just checking the box. Oh, we're gonna get more enrollees if we do, you know, we provide this supplemental benefit.
But really, okay, what is that benefit gonna do to impact health outcomes? Are we going to see lower hospital readmissions by implementing these programs? In terms of STARS measures, are we checking a box or are we really looking at the quality programs? And how they impact the beneficiary's health outcomes.
All of those things are really critical when you're looking at the stability and long-term viability of your health plan. And interestingly, you know, the final, the 2027 final rule was released just earlier this month, and a lot of the changes that we saw within that final rule kind of backed up that statement.
That there we're really looking at health outcomes and quality of care versus just increased administrative burden. So I would view that as a positive, a positive shift and kind of a signal from the administration, uh, to where we should also be focusing.
[00:12:51] Stacey Richter: I'm thinking two things right now. I'm thinking that maybe this is kind of like, let's go back to basics here.
Let's go back to de novo. Like what are we really actually trying to do? And I appreciate that what you're saying. I have been focused, I've had eyes on lately the impact of Goodhart's Law. And what Goodhart's Law is, and it is so applicable in so many different cases, if you start thinking about it. Goodhart's Law is once a measure becomes a target, it ceases to be a good measure.
[00:13:18] Stacey Richter: And I think how I am applying that right here is that if we are thinking of the financials as both the measure and the target. You wind up doing things which inadvertently negatively impact your actual goal. You wind up with this Rube Goldberg machine because you're piling on a lot of things that may not be optimal.
So like, kind of what I'm hearing is, alright, let's just all take a deep breath, take out a brand new legal-sized notebook, right?
[00:13:51] Betsy Seals: Yeah.
[00:13:51] Stacey Richter: And maybe I said legal-sized for a reason and very much just start again.
[00:13:56] Betsy Seals: Yeah. I would say so. You know, looking at the decisions that are being made, the, the benefits that are being provided and really getting, like you said, back to basics and what is a potential adverse impact of any change that we're making.
Really looking at stability versus big flashy changes. And that really by and large from the players who are succeeding right now in the industry. That's what they're doing is really getting back to the basics and focusing on beneficiary care.
[00:14:22] Stacey Richter: Okay. So if we're thinking about, maybe I'm gonna call them the three pillars, right?
Like the three tent poles of a back to basics strategy.
Cookie Jar Compliance
[00:14:32] Stacey Richter: I know one of them that you had mentioned earlier for our first pillar here is, don't get caught with your hand in the cookie jar. What do you mean by that?
[00:14:41] Betsy Seals: Yeah, so I think that that could apply to a lot of things, but I think when we were talking, one of the big things here is right, focus on beneficiary care, access to care, quality of care.
Also don't get yourself in trouble. Don't end up in the news for upcoding. So there's some of those big, you know, flaws, we'll say big faux pas in the program that we see over and over again, decade over decade that really everyone should know to avoid at this point. But somehow still somebody has a great new idea and it ends up getting, you know, health plan's name in the news.
So really looking at those risk adjustment programs as as a prime example, and ensuring that the coding practices and coding guidelines are compliant and that you're not going to end up being found to have upcoded. Really important.
The same could be said of these regulations that have been around for decades really around grievances and appeals.
Prior authorizations would be another big one that we've talked about. So a lot of, you know, “innovation” in terms of AI has been applied to the prior author authorization process. And then a lot of health plans really, um, had to learn a hard lesson, right, about the use of AI in the prior authorization space.
So those types of things, thinking about the impact of these new technologies or new ideas before they're implemented because compliance sanctions not a fun day for anyone.
[00:16:08] Stacey Richter: Yeah. And we talked about the upcoding liberally the last time that you were on the podcast, so if anyone wants a kind of a deep dive into that whole can of worms, definitely go back and listen to that earlier show.
But basically what I'm hearing, if we actually wanna achieve the quadruple aim as a Medicare Advantage plan, if we're trying to get there vis-a-vis shortcuts, let's just say not actually improving patient care, but trying to improve the appearance of patient care, for example. It's not gonna work.
And when I say not gonna work, that's probably a question in and of it itself because it will work for the short term. Like we've seen that before.
[00:16:49] Betsy Seals: Yes, it's absolutely true. A lot of these, you know, strategies, they're exactly what you said. They're short-term strategies. It may work for a year, but it's not going to work for five years. And there may really be the hammer coming down two years from now.
For those of us who have spent careers in Medicare Advantage, it's really interesting because I have seen on the health plan side, everybody has their targets. Everybody has those pressures, and I have seen executives make decisions for the short term. Even possibly knowing that they won't be around for the long-term consequences.
So when we're thinking about the viability and stability of the program, that's what we need to be really considering. Is this, does it have a long-term positive effect or is it a short-term win and a long-term loss? That's really important. I've seen a lot of that.
[00:17:33] Stacey Richter: Which is notoriously difficult for publicly traded companies work in a quarter by a quarter and compensating their leadership based on, what have you done for me lately?
[00:17:42] Betsy Seals: Yes, those pressures are real. That is certainly true. You know, you see the transcripts of those investor calls and you can really understand why those pressures are flowing down the way that they are. But still, every health plan has a compliance and governance process and compliance and governance specialists. So it's really those folks' job as well to ensure that the oversight is there.
And again, it all goes back to beneficiary health outcomes, beneficiary experience. If you're serving your beneficiaries well, if they're not getting held up in the prior auth process, if the appeals and grievance process is streamlined and easy to access, all of those things are gonna have a positive outcome.
You know, those things matter. Call center performance matters.
Prior Auth Reality Check
[00:18:26] Stacey Richter: Speaking of prior auths in serving the beneficiary, there was the prior auth Stats report that just came out for the very first time, and it was pretty stunning, I'm gonna say. And I'm only citing these just to showcase that this will require change management.
There's one gigantic carrier. Prior auth to 12.3% of PA requests. They all were sort of in the same ballpark around 12, 13, 14%. There was one that was lower.
But what was stunning was upon appeal, 95% or more of these prior auths were reversed. So you start thinking, and by the way, only 11% of the prior auths were appealed.
So it's just like, it does not take a rocket science to understand what the financial incentives are there. Like everybody knows that nothing gets appealed. Everybody knows that these entities are playing the float, right?
Like, so I think that's a perfect example of you have a patient who has written care. Who, obviously it was evidence-based if 95% of these are getting through right, like upon appeal and there is a financial incentive to delay. And listen to the podcast with Preston Alexander about the float.
[00:19:35] Betsy Seals: Yeah, so you're absolutely right. And it's interesting, you know, I've spent many years auditing appeals and grievance files, so this is not a surprise to me, but I think it is a surprise probably to the general population, not only the overturn rates upon appeal, but the low appeal rates.
And this is just really sad. When we're thinking about these Medicare beneficiaries, either over 65 or disabled, their provider has requested care, they're denied, and they just don't get the care and a high percentage rate, and that is terrible. But it's a fact.
And so I do believe, strongly believe there needs to be changes to the system, that access to care and beneficiaries being able to access that care easily needs to be at the forefront of those changes. Because I've just seen so many adverse outcomes, not only with auditing these agreements and appeals file, and a lot of times it's the same beneficiary, so you'll get a stack like this, you know, so you're seeing what's happened.
But then also even in my own life, how difficult it is to understand the system if you're not somebody like me who's lived in the system for years. It's not simple. It's not a simple process.
[00:20:47] Stacey Richter: Not at all. And to your exact point, if you're upcoding and you deny care, I mean, there's a chance that a person who actually really doesn't have complicated complications of diabetes or whatever, may not.
But if you're actually risk coding appropriately, and you have a diabetes patient who comes in needing diabetes care and you deny that care, there is, let's just say a significant likelihood that that's gonna cause a very fast medical repercussion downstream.
So to the point that you're making, like what I'm hearing is earn the money fair and square?
[00:21:20] Betsy Seals: Yeah. There are a lot of other programs that could be effective in impacting financials. This prior authorization game is a slippery slope.
[00:21:29] Stacey Richter: What I'm kind of taking away is that there is in fact the a correct a better strategy at a minimum moving forward here, which is go back to basics. Do it right, just do it right.
If you've got a patient at rising risk, figure out that they're at rising risk. We had Dr. Scott Conard (Episode 462) talking about how it is so much less expensive to find patients at rising risk and to make sure that they don't turn into high risk, high costs, right? Like there, there are ways to do this that are aligned with better patient care and then there are ways that are not. So, yeah.
[00:21:58] Betsy Seals: Yes. To your point, you know, looking at predictive analytics for members who are likely to develop diabetes or members who are likely to have an emergency and need inpatient care. All of those abilities are there. Just like AI, predictive analytics have really been enhanced over the past several years. And so looking at those programs and how to intervene before those diagnosis or before that adverse event is an example of back to basics.
One thing when it comes to the use of AI that we've seen a lot of players implement, it's never used to deny care. Right. If it's an easy yes, that might be one thing, but if we're talking about denying care that a human being's eyes, a clinician's eyes should always be on that file.
[00:22:43] Stacey Richter: I hope you're right.
Back to basics. There is ample advances in predictive analytics. There's also robust evidence that Advanced Primary Care is the way to go. And yet, you know, for example, my mother is in a Medicare Advantage plan, cannot get a primary care doctor, right?
So like there's plenty of pretty obvious strategies which are in fact aligned with better patient care. And I think that's the point that you're making here. Go back to basics. You don't need to get your hands stuck in the cookie jar. Just do it. Do it right. And then you don't need kind of these workarounds which are, which are questionable, at best.
[00:23:17] Betsy Seals: Absolutely.
Serve The Right Members
[00:23:18] Stacey Richter: The second, kind of back to basics tent pole, focus on the beneficiaries that you actually serve well. What do you mean by that?
[00:23:26] Betsy Seals: If you look, again, across the nation at what's happened over let's say the last five years, a lot of these large national players that ended up pulling out of markets, some of that was due to kind of, okay, we're doing well here. We're gonna copy and paste that method and, and apply it over here.
What works in LA County isn't gonna work in Baton Rouge. You really have to understand the population that you're serving. And for a local plan, I'd say it applies to national plans too, but let's just say for a local plan in this example, really look at those beneficiaries and those chronic conditions that you are succeeding in serving well.
A lot of what we see is that health plans will be kind of adversely selected. You know, a large national player will leave all those beneficiaries, then join the regional plan. That plan has no idea how to serve those beneficiaries because they have a whole host of other conditions and behaviors than the core set of beneficiaries.
So really focusing on if we're doing a great job with our diabetic members, or predicting diabetes and preventing diabetes, let's really focus on those programs. And in our marketing and acquisition processes and programs, focus on attracting beneficiaries that we know we can serve versus just attracting anyone regardless of whether we can serve them well.
[00:24:37] Stacey Richter: What does that look like on the ground? In other words, is that a marketing endeavor or is it more than that?
[00:24:44] Betsy Seals: Again, implementing predictive analytics in your marketing, understanding the beneficiaries within your health plan, understanding what different chronic conditions or social behaviors are within that population and then creating, you know, your member acquisition strategies influenced by some of those pieces of information.
Now, we're never going to cherry pick beneficiaries, right? That's a big no-no. However, we have to be realistic about what we can and cannot do well.
And so it comes to beneficiary acquisition, it comes to plan benefit design, right? It comes to rewards and incentives programs. All of these pieces are really part of the equation here.
[00:25:24] Stacey Richter: This is kind of reminding me of some of the special needs plans also.
Mm-hmm.
[00:25:29] Betsy Seals: Yes. Yes. And so there's a couple of different types of special needs plans, of course, dual eligible Special Needs Plans serving Medicare and Medicaid eligibles. One interesting trend that we've seen over the past couple years is the chronic SNP plans. We saw nearly a 50% growth in chronic SNP beneficiary enrollments.
[[00:25:46] Stacey Richter: SNP, that is an acronym for Special Needs Plan.]]
[00:25:52] Betsy Seals: And so those plans are designed to serve certain chronic conditions, and they can be different chronic conditions depending on the population present.
So that's a strategy that we've seen work really well when it comes to, okay, you know, again, we, we serve the diabetic population really well, so we're creating a chronic SNP plan based on serving that diabetic population. Now we can have special benefits and special programs to do an even better job.
So implementing some of those Special Needs Plan strategies is a really great way to get kind of at the core of serving those beneficiaries.
[00:26:27] Stacey Richter: And we did talk about this also the last time that you were on the show at some length.
And as you mentioned, there's also around some of the different languages or the different cultures also can have their own very specific needs met.
So our second pillar here is focus on the beneficiaries that you actually serve well. Like figure out what that means even.
[00:26:48] Betsy Seals: Yes.
[00:26:48] Stacey Richter: And then really understand what it's gonna take to actually improve these beneficiaries, health, and wellbeing. And then do that.
[00:26:57] Betsy Seals: Yes, apply the same effort to those you know pieces as you are to prior authorization process or risk adjustment process or blanket beneficiary acquisition. Those same strategies and same analytics could be applied to the current population and the impact can really be significant.
So certainly something to focus on.
[00:27:17] Stacey Richter: I like when you say the impact can be significant because what I'm hearing is the impact on these members health and wellbeing can be significant, aligned with the financial rewards that should come from that. Again, there's a difference between profit and profiteering.
Andthe more I'm sort of listening to you talk, the more, I'm defining profiteering: as making money when the patients and members that are being served are worse off, right?
[00:27:43] Betsy Seals: Yes.
Stars Done The Right Way
[00:27:44] Stacey Richter: The third pillar in our back to basics, overarching strategy here is around STARS in clinical programs. Really thinking about how do they improve health.
[00:27:55] Betsy Seals: You know, in the 2027 final rule that was released, we did see a streamlining of STARS measures as we expected to, and a lot of that streamlining was finalizing changes to reinforce areas included in STARS to further drive quality of care and reduce regulatory burden.
I think that that's really important. When we're looking at STARS, of course, we all know that there's huge bonus payments, but STARS measures and I think CMS is really indicating this in their changes. Should be about health outcomes. It shouldn't just be a check the box, right? It should be, does this impact the beneficiary in a positive way?
So a great example I'll say in that we've seen is the secret shopper, call center calls that have been all over the news in the STARS arena. And is that a really an indication of beneficiary quality of care or access to care? Because these are secret shoppers.
And so really focusing on those measures that do impact beneficiary access to care and care outcomes is important.
And more than just what CMS is doing by streamlining STARS measures and kind of overarching the approach internally as well. More than a check the box, looking at the clinical programs involving the clinicians in those decisions around stars strategies is really critical.
[00:29:11] Stacey Richter: Yeah. And this is something that oftentimes provider organizations figure out sometimes the hard way, just relative to trying to game equality measure. Right. And again, kind of back to Goodhart's Law, there's a couple ways you can, for example, reduce readmissions. One of 'em is throw everybody in observation. Do things with coding. Right?
But like, again, what is happening there is we're not actually changing the underlying situation, at all. We are maximizing the financial benefit from what is going on. And at a certain point, I'm gonna come full circle. You're gonna get your hand stuck in the cookie jar. Right? So.
[00:29:52] Betsy Seals: You know, I've just seen it happen over and over and over again and I, I think if anybody could see my face right now, they'd understand where I, where I stand on these issues.
But it's, you know, short term fixes, I really believe that there's an ethical component to all of this. Again, because this is our senior and disabled population of our nation, there is an ethical component to implementing a program that is, you know, a check the box for bonus dollars, but has an adverse impact on a human being.
I think we should all require ourselves to think about those things.
[00:30:26] Stacey Richter: Yeah. Which is something that we talk a lot about here on Relentless Health Value. Just 'cause you have the power to go low.
[00:30:32] Betsy Seals: Yes.
[00:30:32] Stacey Richter: Let's all have the integrity to do things the right way.
[00:30:35] Betsy Seals: Inevitably, you know, I would say not 10 times outta 10, but nine times outta 10 you're gonna get caught because there's gonna be a new administration, they're gonna do a look back.
It's also just not worth it. My personal opinion.
[00:30:48] Stacey Richter: Yeah, I mean, there's two sides to AI too. On the one side, you can do fun stuff to try to game the system or automate whatever. But then also on the flip side, others can use AI to figure out exactly what you're up to. So it is an arms race. Why not? Why not try to do it the right way?
[00:31:04] Betsy Seals: Yeah.
Advice For Independent PCPs
[00:31:04] Stacey Richter: Do you have any advice right now for example, independent practices with Medicare Advantage patients, particularly primary care? Like, is there anything that that gang should be thoughtful or thinking of?
[00:31:18] Betsy Seals: I think that there's a lot. Of course providers, individuals, say PCPs are involved in this whole prior auth process.
What we see as you know, is a lot of times at the provider appeals on the beneficiary's behalf that has a significant impact. Providers are often compensated based on bonus payments that health plans received. Based on risk adjustment coding practices.
So I think really understanding at the provider level, the upstream impact of your practices within your provider practice is important because they're busy, right? They're focusing on serving their patients.
But in those contracts with your MA plans, there's a lot that's flowing down. So just kind of understanding your part in that equation and how your internal practices of your office are gonna impact the beneficiary and also the program, I think is important.
[00:32:07] Stacey Richter: Yeah, and vice versa, right? I have heard more than once now. There are PCP practices who are like, I don't get compensated for prior auths. They're so arduous. I have no idea what's going on. So you know what? Anytime a patient needs a lot of prior authing, I just send 'em to the ER. Because you know what? You don't need a prior auth over there.
I think a lot of times executives model something out and they just assume that everything's gonna trickle downhill, and there's gonna be no lashback or perverse incentives that impact them.
But if you have all of the patients who could have easily been seen in primary care, but wind up in the ER for the most expensive primary care that money can buy, you just hope that it doesn't become a death spiral where the prior authorizations are actually increased.
Because to your point, if somebody isn't, doing their due diligence at the plan level, understanding what the impact is of some of these downstream decisions, and then just doubles down on an existing strategy that is creating actually higher expenses. Here we are.
[00:33:02] Betsy Seals: Yeah, that's a big problem. To give some credit, we have seen some of these large players kind of come together and make this commitment around streamlining and modernizing the prior auth process, and we have seen some positive improvements based on that promise, I'll say.
I think there's hope, but there's a lot, a lot more work that needs to be done, both from the health plans doing it themselves, leading this innovation themselves. And I believe also from a regular standpoint, because there has to be teeth as well behind some of these practices.
[00:33:34] Stacey Richter: Yeah. And if the backstop is lobbying, which there was just a, Bob Herman just wrote in STAT that he wrote, "Regardless of what officials say about holding insurers accountable, the track record shows insurers are winning on policy right now as a result of of excellent lobbying."
[[This article by Bob Herman about the effectiveness of Medicare Advantage lobbying on policy.]]
Stabilization Outlook Wrap
[00:33:59] Stacey Richter: Betsy Seals, is there anything that we haven't discussed that you think would be really important?
[00:34:05] Betsy Seals: I wouldn't say that anything that we haven't discussed.
What I would say is for MA players and all of the downstream companies that are impacted by what's happening at a regulatory level and what's happening in MA enrollment trends, I think my message would be that, again, we're in a time period of stabilization.
We've seen this before. We saw it in 2016, enrollment numbers drop. We're seeing it now, interestingly, just 10 years later, and that's kind of your typical cycle. We have also had COVID in the middle of that.
So I strongly believe, and all of my industry colleagues that I've spoken to about this, also strongly believe in the long-term viability of the program.
[00:34:44] Stacey Richter: Betsy Seals, if someone is looking for more information or looking to contact you or reach out, where would you direct them?
[00:34:51] Betsy Seals: Of course, I would direct them to the Rebellis Group blog, certainly for industry updates, and I can actually still be reached at bseals@rebellgroup.com.
[00:35:00] Stacey Richter: Betsy Seals, thank you so much for being on Relentless Health Value today.
[00:35:03] Betsy Seals: Thank you, Stacey.