Payers serving the Medicare, Medicaid and Dual Eligible markets are facing many challenges and opportunities in the wake of health reform. The projected membership growth for these markets is tremendous. Payers must be able to scale for growth, while aggressively managing compliance, lowering administrative costs and improving the cost and quality of care as they compete in the retail market.
Medicare Advantage plans also must focus on quality of care, member and provider satisfaction, as these have a direct effect on Star Ratings and, ultimately, on quality-bonus payments and the ability to conduct year-round enrollments.
The Medicaid arena also presents major challenges. Although opportunities exist for dramatic membership growth in response to state Medicaid program expansion and new populations entering the program, payers serving this market must find new ways to manage revenue as state reimbursement rates decline. Another approach may be to intensify the focus on care management programs that address the medical costs associated with this population.
Dual eligible individuals are among the sickest and highest users of healthcare services and account for a disproportionately high amount of Medicare and Medicaid program expenses. Duals often face a high amount of fragmented care as most of their primary care services are delivered through Medicare, while most of their long term services and supports are delivered through Medicaid.
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