Learning to Share, Doing the Right Thing and Bracing for the Boomers – Belle’s Q&A with Tracie Fahy

Tracie Fahy has more than two decades of experience in the healthcare industry, ranging from internal operations to market management. She is a valued member of Belle’s strategic advisory board. Tracie currently consults with health plan and provider groups across the country. Previously, Tracie served as President of Humana Medicare for North Florida.

How Are Baby Boomers Who Are Aging Into Medicare Changing Things?

Baby boomers don’t want to be told what to do. That’s why plans are trending toward letting members choose how they spend their money by providing flex dollars instead of offering specific supplemental benefits. Providing cash cards that can be used for basic needs, such as paying monthly utility bills and rent, is gaining in popularity. Also, a lot of the new ideas and concepts being generated rally around addressing barriers for people getting care. Specifically, how do we make it more convenient? The baby boomers are saying, “I want you to come to me, or I go where I want, on my terms.”

That’s why you’re seeing growth in PPO within Medicare Advantage plans. While MA members currently enrolled in HMO plans will probably stick with them, those aging into Medicare seem to prefer a PPO plan, because that’s the environment they have grown accustomed to by virtue of participating in Healthcare.gov. These new entrants are looking for ungated plans that offer the freedom to do what they want and to have more control, even if it means higher copays.

Many MA Plans are Struggling to Maintain High Star Ratings. What’s Happening and How Do Plans Adjust Their Strategy?

Medicare Advantage plans have spent the last few years being squeezed on premiums, while also seeing the goal posts continually moving when it comes to earning quality bonuses through the Stars program. It seems every time plans get good at it, the target moves. I think one of the things plans could do moving forward to combat this is to better anticipate what is coming next. They have a lot of data they can mine for insights. They can also look at which innovations are gaining traction, and thus acceptance, in the market. CMS is analyzing trends and data and making decisions on which quality measures are most meaningful in terms of impacting members’ health. Plans should make sure they are doing the same.

How Is the Industry Doing When It Comes to Chronic Care Management within Medicare Advantage Populations?

If a diabetic member’s foot hurts, they are going to the podiatrist. If they develop a wound, it’s a visit to the ER, pending authorization for wound care. While the primary care physician should be a patient’s guide, the “gatekeeper” model does not make it easy to get comprehensive support for chronic conditions. Members are not consistently receiving holistic care. You see terms like “population health” and “whole person health” used all the time, but what is meant by those terms? When you’re talking about people with multiple chronic conditions, getting basic care often, such as preventative or supportive care in the home to include evaluation of their environment and support system, is whole person care. There are lots of things we can improve with the way we support chronic disease, but the most impactful thing we could do as an industry is to get better at preventing it. We can tell when diabetes is coming. We know when someone is going down the path to chronic disease and what that entails. We just have to do a better job of getting ahead of it, using every available medical, behavioral or social insight we can capture.

So, Bringing Care to the Home Is Key. How Do You Make That Work?

If you’re going into the home, you have to provide tangible value. You can’t just pop in, ask a bunch of questions and give members a directory of resources. Are you spending sufficient time with the member to gain trust and capture risks? Are you holistically evaluating their needs? Are you offering clinical benefits? Is the member excited to welcome you back again? You also have to make sure any efforts that are home-based effectively link back with providers to build a better clinical picture and create more coordinated care. There are many organizations being sent to the home, but I’m not sure there are many who successfully check these boxes.

Any Other Specific Thoughts for Improving Support for Members with Complex Needs?

We need to learn how to share as an industry. Health plans have data. Hospitals have data. Primary care physicians have data. Specialists have data. All this data is super fragmented, and everyone is hesitant to share what they have for fear of someone else stealing a patient or the creation of liability, etc. It leads to a lot of disconnects with patient care. I’d like to see universal sharing of lab data, as one way of improving this situation. Such transparency in the pharmacy industry has led to many positive outcomes. A simple example is the ability to prevent a single patient from receiving multiple opioid prescriptions. If we had the same type of transparency in labs, doctors could collaborate on lab patterns linked to treatments, behaviors or lack thereof.  This effort, like those attempted with radiology testing, can also save significant amount of money by reducing duplicative and unnecessary testing.

You Believe Doing the Right Thing Will Lead to the Right Outcomes. Can You Elaborate?

I’m passionate about the patient and doing the right thing for every individual. If the doctor believes a specific action is the right thing to do for a specific patient, it should be done. And if the right things are done, even if they cost more in the near term, we will achieve the right outcomes down the road. The upfront battle of proving ROI to gain approval for new unconventional services, when it’s clear they 100% will improve care for patients, frustrates me. Unfortunately, it’s getting harder for the industry to keep the patient front and center. Despite prioritizing “quality” the last decade, payers and providers are dragged into focusing on costs and claims. It’s easy to lose sight of the individuals we’re serving, when we are knee deep in spreadsheets and crunching the data. We have to find ways of not letting processes and protocols outweigh what’s right for the human being sitting in front of the physician.

What’s One Trend You Have an Eye on for the Year Ahead?

There’s a growing wave of people who are leveraging the Internet, digital solutions and AI to self-treat. For those who have a desire to take more control of their health and be more proactive, there are endless opportunities to turn to supplements, vitamins, nutrition and exercise programs and other self-care offerings. Individuals can easily screen for various things on their own as well and interpret their own lab results. The more barriers to care we remove, the more likely people will get the care they need, so I see this trend as a positive development. However, from the provider and payer side, we need to take swift action when we are presented external observations such as lab results, social risks, cognitive decline etc. trending in the wrong direction. We need to find and accept creative ways to stay connected with patients outside of the traditional office setting so they trust we have their whole life top of mind.

Stay tuned for additional Q&A articles featuring industry experts. Want to hear more from Dr. Wilson? Have an expert you’d like to recommend we interview? Contact us here to continue the dialogue.