Why successful Medicare Advantage plans prioritize clinical engagement

The ground under the Medicare Advantage (MA) program is shifting. A complex interplay of evolving regulations, increasing member expectations, pressure to improve quality, and market consolidation is making success anything but a given.  

The good news for MA plans is that the number of seniors selecting MA plans over transitional, fee-for-service plans is growing. The less than good news, however, is that in order to effectively compete for these members, MA plans need to do more to control costs and improve quality.

To meet their cost and quality goals, MA plans depend heavily on their provider network. They have to find new and innovative ways to engage providers, without adding to providers' already hefty administrative burden. Fortunately, advanced value-based care software offers promising opportunities to boost clinical engagement, helping MA plans and providers successfully align and achieve their goals.

The current Medicare Advantage (MA) landscape: doing more with less

Regulatory pressure

Since the inception of value-based care decades ago, health plans have faced the imperative to better control costs while improving outcomes. Still, regulators continually up the ante. For example, Medicare benchmark cuts are slated to decline by 0.2% this year, and CMS expects all beneficiaries to be in plans with both upside and downside risk by 2030.

Slowing enrollment growth

At the same time that the pressure to meet value-based care goals grows, MA plan growth is slowing. While enrollment is still increasing—by nearly 4 percent this past year—the rate of growth has decreased since 2021. And MA plans leadership is increasingly expecting worse enrollment growth, as demonstrated Chartis’s annual MA plan survey. Plans must become increasingly competitive to compete for a smaller slice of the membership pie.

Smaller provider networks

Finally, MA networks are shrinking. More than half of MA leaders expect network participation to decline this year, according to the Chartis survey. This is due to several factors, including declining Medicare rates, stricter CMS standards for network adequacy, and market consolidation.

The upside is that narrower provider networks can make it easier to strengthen clinical engagement. In fact, nearly 70% of MA plan leaders expect to increase this collaboration with providers this year, according to the Chartis survey. In the report, one leader said: “Carriers have to find a better way of collaborating with providers, and the more we collectively realize we are in this MA business together and try to work on controlling overall costs of care, the better.”

Why clinical engagement is so critical

With so much shifting for MA plans, plan leadership has no choice but to prioritize the relationship with their providers.  

Rising disputes between payers and providers make collaboration essential.

Unfortunately, payers and providers are increasingly facing disputes related to reimbursement and other contract terms. Last year saw the highest number of publicly reported disputes in recent years, an over 50% increase from the year before. Unfortunately, nearly half of those disputes failed to reach a timely agreement. As Medicare rates decline and payers face increasing pressure to cut costs, the industry is at risk for even more disputes, making stronger plan-provider relationships an urgent imperative.

Many providers still need to experience the benefits of value-based care.

While providers may be on board with the aims of value-based care, many are failing to experience any benefits from the transition, making it challenging to fully engage them in MA value-based goals. Providers worry about the impact of the transition on financial performance as well as staff burnout. To build provider champions and fully align on goals, payers need to work more closely within their provider network to identify the right incentives and establish goals that do not add to clinicians' already overwhelming administrative burden.

Meeting the new Administration’s expectations related to cost reduction requires close alignment with providers.

Though it is early into the new Administration, several actions indicate that payers will face increased scrutiny, particularly when it comes to cost reduction. If MA plans want to demonstrate to CMS real results when it comes to controlling costs, they need the participation of their provider networks to reduce unnecessary procedures, prioritize early interventions and care gap closure, and thoroughly document patient conditions.

Payers need strategies to remain competitive.

MA leaders are prioritizing Star ratings, risk adjustment, and healthcare costs in their 2025 goals, according to the Chartis survey. These priorities point to the critical importance of financial performance and profitability. Without working closely with providers, MA plans will not be able to move the needle on these priorities.

How clinical engagement drives value

Fortunately, when plans and providers work together to align on key value-based care goals, they can more effectively control costs, improve outcomes, and provide optimal member experiences.

• Engaged clinicians improve documentation accuracy. When payers work with providers to ensure they have the tools and information necessary to close documentation gaps, they can improve risk adjustment accuracy and financial predictability. Providers, in turn, gain insights into how care delivery impacts reimbursement and outcomes, motivating them to prioritize accurate and complete records in future encounters.  

• Active provider involvement helps close care gaps. Engaging clinicians and working to generate aligned, mutual goals helps leading to higher quality measures and better Star ratings. Plans and providers both meet their value-based goals, support patient outcomes, and help attract new members.

• Member satisfaction increases with clinical engagement. Providers and payers that are closely aligned help improve member experience, increasing retention and strengthening competitive positioning in the MA market.

The impact of technology on clinical engagement

Technology like Reveleer’s value-based care enablement platform can facilitate streamlined payer-provider collaboration by improving data management, offering seamless data integration, and providing powerful reporting and analytics capabilities to measure performance on shared goals. Here are a few of the capabilities clinical engagement technology can offer:

• Extract data from disparate sources so that providers and payers can both benefit from centralized patient data pulled from EHRs, claims, HIEs, and other external sources.

• Quickly integrate data into comprehensible formats, including structured and unstructured data points, using artificial intelligence.

• Generate clinical insights from data with 99% accuracy and deliver them at the point of care to close care and diagnosis gaps.

• Provide real-time analytics and bi-directional data exchange to support proactive risk adjustment and quality improvement initiatives.

As MA plans face a future of narrowing networks and rising expectations, prioritizing clinical engagement—supported by advanced technology—is not just a strategy, but a necessity for sustainable success. Interested in a technology partner that can help boost clinical engagement and strengthen provider relationships? Learn more about our powerful Clinical Intelligence Solution today.

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