How Medicare Advantage plans support our seniors

Tune in to this episode of “Good Health, Better World” to learn more about the origins of Medicare, the types of benefits and services available through Medicare Advantage plans, and what is on the horizon for these plans in 2025. Hear perspectives from UPMC Health Plan and the Alliance of Community Health Plans (ACHP).

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Episode Transcript

Ellen

Stronger communities begin with good health—for everyone.

You’re listening to the “Good Health, Better World” podcast from UPMC Health Plan. This season, we’re exploring the joys, challenges, and opportunities associated with healthy aging. We’ll talk about what it means to age well; how to care for body, mind, and spirit as we get older; and the tools and programs available to ensure a good life, throughout life.

I’m your host, Dr. Ellen Beckjord. Let’s get started.

In this episode, we're joined by Angela Perri and Ceci Connolly to discuss the landscape of Medicare policy. We'll learn about how Medicare has evolved over time, consider some of the challenges and opportunities of Medicare, and hear about the work being done at UPMC Health Plan, as well as the Alliance of Community Health Plans, or ACHP.

Ceci, Welcome to “Good Health, Better World.”

Ceci

Great to be with you, Ellen.

Ellen
Angela, thank you for joining us on “Good Health, Better World.”

Angela

Looking forward to it.

Ellen

Ceci, if I could start with you, can you explain how Medicare came to be and how it's evolved over time?

Ceci

Of course. And, such a great topic. I'm thrilled to be joining you both. Medicare, of course, was part of the Great Society effort by LBJ in the '60s. Also, the creation of Medicaid at the same time—another terrific program, maybe for another episode—but Medicare specifically is a federal health program that serves people over 65 as well as individuals with disabilities. It began as what we call a traditional fee-for-service health program, in which basically, the federal government was paying for hospital and doctor care for America's seniors.

But what's really exciting in the recent past is the creation of a public-private partnership that's known as Medicare Advantage. And this has brought some very creative competition into that senior health program. So, a few of the things about Medicare Advantage—and it's very much for the senior to decide which way they want to go—but more and more seniors now, about 54 percent of the Medicare population, are choosing a Medicare Advantage plan. It's run by a private health plan, such as UPMC, such as our members at the Alliance of Community Health Plans. And it typically includes prescription drug coverage. It may have vision or dental benefits. There could be a nutrition component for some individuals or a transportation benefit. They really get to shop around and kind of find what fits them.

And I have to underscore that prescription benefit because as everyone knows right now, the price of therapeutics has gotten so high. For a senior citizen to not have some of that coverage can be very difficult and very terrifying. And we've all heard these stories about people that are cutting pills and skipping medicines because they can't afford it.

So the other thing that I'll say about Medicare Advantage, two more things I'll just mention here. The first is, and this is really the model that excites us, and it's, UPMC is a perfect example. Medicare Advantage is intended to get your clinical team working with your health plan. So it's a very coordinated, integrated approach with everyone working on behalf of the patient or the consumer.

And when you've got it all coordinated that way, things should go a little more smoothly. Everybody seeing the right information about you so that they can keep up to date on your preventive screenings. You know, what do you need in terms of a vaccine in the fall? All of that sort of thing. So, we really like that model of the integrated approach, which is a hallmark of Medicare Advantage. If you're in that traditional fee-for-service, you're a little bit on your own going out there and sort of putting your team together.

And finally, I will mention that Medicare Advantage, because of this public-private partnership, the government insists on scoring the plans on quality and other important metrics. So, when seniors go to shop in the fall during that open enrollment season, they can actually look up the quality scores and they can shop based on convenience, price, and quality.

Ellen
Angela, I'm going to ask you a question. And then I know it's one that you and I could talk about for hours, because I know how passionate you are about caring for our senior population. But through your lens as our chief Medicare officer: Why is it so important that we care for our senior members in this way?

Angela

Well, any great society should. So, we'll start with that. But really, if you think about the need that's there; as we age, our health tends to deteriorate overall. That's just part of the human condition, as it goes. So, understanding what that means for all of us, it's different for every single person, but it's also part of just the overall structure of health and life.

And when we think about our seniors today, everyone wants to age well and preferably at home. The most important thing is, is to do it our way. Every individual is entitled to dignity and respect as part of the overall process of aging. And what Medicare does, and Medicare Advantage in particular, is help you on that health journey. That's what it's designed for.

To Ceci's point about traditional Medicare, traditional Medicare is also more expensive. There's a 20 percent co-insurance, that seniors have to have, and have to be responsible for. And in the Medicare Advantage space, there's something called a maximum out-of-pocket. It's a predictable, guaranteed cost for them. So, as you age, you also tend to have less money than when you were fully employed or as part of that process. So having a fixed income or having a particular budget that you want to manage over the course of aging, when conditions get more complicated, or being at home and being mobile in your home or being active in your home is really important for, you know, sustaining your quality of life, all of these things are part of how we think about health care in the Medicare Advantage space.

It's designed to be holistic versus episodic. And I think that's a really important thing as you age and as our seniors are making decisions about who can best help them on this journey. These are the questions that we want to ask and answer.

Ellen

I appreciate you calling out that contrast between, you know, as we get older, the likelihood of being on a fixed income gets higher, and the unpredictability of our health-related needs goes up as well. And so being in a Medicare Advantage plan that has the opportunity to be flexible and personalizeable and as you said, Ceci, really build a team around a person as their needs change, even if they can't all be predicted, could be a really powerful support for that stage of life.

Angela

And should be.

Ellen

And should be. Ceci, what are some of the challenges and opportunities that are facing Medicare right now?

Ceci

Oh, good question. And I'm going to love for Angela to jump in here on this as well. And I might just mention one other additional thought because I think it ties in with some of Angela's context here.

You know, in looking at our ACHP members and including UPMC—and I'm going to brag on UPMC, because Angela is going to be modest about the incredible program that she's running here—but our ACHP members outscored all of the rest of the competition, which is typically the large, publicly traded, for-profit insurers, on 35 out of 42 metrics. And these are metrics such as your preventive screening, the patient experience, drug safety, and understanding your costs. So, it really goes right to Angela's point of the things that can be very relevant to seniors.

So, you did ask about challenges to Medicare and Medicare Advantage: Cost. And again, I'm going to come back to prescription drugs. The current administration, with Congress, did pass some legislation. It was called the Inflation Reduction Act. It's now negotiated the prices on the big top 10 drugs in the Medicare program. That should start to bring some relief to seniors. I know my mother's on one of them, and it cost a fortune. So, looking forward to that change. But cost is going to continue to be a very big issue in all of health care, but especially in the Medicare program.

So that's really where you're looking, again, for these integrated systems that can do the good job of being very efficient with the seniors’ dollars. There are also—and I won't get too in the weeds—but the current administration has a very big focus on health equity, which we love at ACHP. We are enormously supportive of it.

They've established something for the future called a health equity index. But the problem right now, and this is really kind of a glitch in the way they've designed this incentive program—a lot of plans won't qualify. They won't even get to compete on that health equity index because they may not have enough volume. And so, we're really working with people in Washington just to make certain that that threshold is not going to be the barrier to the very high-quality plans being able to compete on health equity.

Ellen
I'm glad to hear that, because, of course, health equity matters tremendously, no matter how big your member population is. So, thanks for your advocacy on that.

Angela

I'd like to chime in just a little bit on a couple of Ceci’s points. We are huge advocates of health equity, but that's really a buzzword right now. And that's because it's become more of a reality that there are social determinants of health that really impact outcomes, impact someone's ability to just go to a doctor, impact affordability and access and all of these things.

At UPMC, that's been something that we've considered as part of the tapestry of health all along. It's not a buzzword for us. It's not something that's new. To Ceci's point about challenges on cost, we do applaud the Biden administration for coming forward with a $35 cap on insulin. At UPMC, we did that five years ago. So, my response to that was, “Yay!” And, “Welcome to the party; you're fashionably late.”

We did that mostly because everything that we do is around affordability and access. We want people to be able to afford and to take their medications. That's part of, you know, living a healthy life and being able to have a quality of life overall. So, we're very intentional around those designs, around how we think about those things.

But from a challenge perspective, how the regulations dictate to us as a health plan (or sometimes as a health system), what we're allowed to do within certain constructs or constraints—from benefit design, to the health equity index and other things—doesn't always align to a practical reality. And so, part of it is partnering with Ceci and ACHP to advocate for Medicare Advantage for Tomorrow.

We're thinking about, how can we make this better? There's a lot of really good foundational things that exist that allow for seniors to have a full complement of services. So, to her point about it's not just the physical health. There's behavioral health, there's dental, there's vision, there's supplemental benefits and services. But as part of that benefit design, what we at UPMC are doing is really trying to tailor that to our communities.

Not all communities are the same. Some have food deserts. Some are more urban setting[s]. Some in the rural settings have miles to go to be able to access specialists or just basic care with their primary care physician or others. So, we also support things like telehealth and telemedicine and trying to creatively come up with solutions to help solve for our seniors.

And the challenges are great around the costs. Overall, we're seeing a lot of pent-up demand coming out of the pandemic, a lot of delayed care. With that delayed care comes complexity, and therefore it makes things even more challenging for our seniors, for our physicians, for our health systems to be able to adequately coordinate and make sure that we're evaluating the complexity with our seniors.

Ellen
And that's a unique moment in time, I think, because there's just the underlying care that's needed, and the population is aging and [there is] probably some incremental increase in complexity at a population level generally. But to layer on top of that, the continued long tail of the pent-up demand from during the time during the pandemic when people were not able to receive probably-needed levels of care and deterioration over that time. So, it's a remarkably unique and challenging time in the ways you've described.

You've both talked about some changes coming on prescription drug costs. Thank you for that. Are there other changes happening in 2025 that people should know about, either with respect to UPMC Health Plan Medicare Advantage in particular (and Ceci, anything you'd like to add from ACHP's perspective), but other near-term changes in 2025 that folks should be aware of?

Angela
So Ceci mentioned the Inflation Reduction Act. This is a multi-year change management exercise, I would say. It's beginning this year in 2025, to start with. But the other thing is that there's multiple layers of regulation that was introduced in 2023 and 2024, some of the most that we've seen since the Affordable Care Act, in everything from payment models and value-based care, to the quality program and how that's being evaluated, to benefit design that's impacted by all of this cost and utilization. I can't go a day without new articles on Medicare Advantage and the challenges and the different things that are there. But what I can say is, with all of this regulation change, the most important thing is for our seniors to have confidence in their partner.

And UPMC prides itself on being that partner in care. I have a hashtag, #GrandmaCenteredCare, or #GrandpaCenteredCare, because, you know, it's really important that we be that partner for them and that everything that we do revolves around them. So, it's not necessary to know all of those regulations and things. What's more important is that it is our job to create and maximize benefits and services and programs that allow for our seniors to have access and affordability, first and foremost.

Ellen

What I hear you saying is that the way we're approaching it at UPMC Health Plan is, our focus on keeping the member at the center of all of our decision making doesn't change even as regulations do, even as new constraints or parameters come into play. That's our focus and we work as creatively and innovatively as we have to, to adapt to the changing landscape, as policy changes, as it can and should and will. We reconfigure around the member in whatever ways we have to, to keep affordability, access, personalization, and support at the center of our approach to supporting our members with the benefits that we build and offer.

Angela

100 percent. This is a highly competitive market, and that creates innovation, that creates a challenge to constantly be thinking about, what else could we do? This is where aging at home comes into play. What we're thinking about is, how do we help people age at home? How do we start to think about benefit design in a way, or supplemental benefits, that allow for choice and allow for people to start to think through, what does it mean for me to be able to age at home? Do I need to think about my stairs? Do I need to think about access a little bit differently? How will I have transportation and what will that look like? How am I saving for my future? What does that mean to me? And we as your health plan are trying our best to create programs and services and that includes teams that help coordinate across all of these different areas. We don't just limit it to physical health or a behavioral health episode or activity. We're thinking about it very holistically and from that family and that caregiver perspective as well.

So, the ability to innovate in this Medicare Advantage space and the competition that gets driven as part of this process, to Ceci’s earlier point about this being a public-private partnership, we have to be very good stewards of public funds. These are tax dollars, and we take that very seriously because we all contribute to the Medicare fund. And there's a trust that comes along with that, that we are maximizing those dollars in a way that's going to best serve our seniors.

Ellen
Ceci do you have any additional thoughts on innovation and Medicare Advantage?

Ceci

Sure. And Angela mentioned it and I really appreciate [it]—we at ACHP, working with our members, including UPMC, over about 18 months, we put together what we really consider the vision for the next generation of Medicare Advantage in the spirit of innovation, modernization, and really continuing to serve future seniors.

We call it MA for Tomorrow. It's on our ACHP website for anybody who wants to look. We put this under five big pillars. To give you a little flavor, we're saying the current quality measures in MA are good—and again, our members are dominating the four and a half and the five stars, so we're pleased about that—but we believe that we can go higher in the quality. So, we have identified ways to really raise that quality bar, also take some burden off of your clinical team by not doing as many of the sort of administrative reporting, but really focusing on what are those patient health outcomes and what's the patient experience.

And, taking a look at those, you're really starting to get at quality and performance. So that's part of our vision. We also have provisions in there. We call it consumer navigation. But we want to constantly make certain…because seniors do have to do the shopping. And you know, that can be complicated. There's so many choices. There can be a lot of that mumbo jumbo health care stuff, deductibles and copays and everything.

So, we're constantly working with the administration and our member plans just to make certain that the consumer navigation is going to be as simple and straightforward as possible, that they can get at the important information—not only price, but again, what's the quality rating? Where would I go for my care? Could I have virtual care? That kind of information if you're out in a rural community, especially. And who are the other helpers that can advise seniors in a very independent, trustworthy, credible way? I do want to caution for some folks, you know, thinking about enrolling this fall, you want to be careful because there are some that are going to be selling for a company, and there are going to be others that are just knowledgeable advisers made available to you. So, trying to be good smart shoppers is important, but we very much think, you know, we use the cliche we can take MA from good to great.

Ellen

Is there anything else either of you would like to share with our listeners as we close? And Ceci, I'll start with you, and then Angela would ask you and including other ways you'd like to comment on how UPMC Health Plan’s Medicare Advantage products really stand out.

Ceci

Well, I'm just going to say, Ellen, it's such a treat to be here at UPMC with you and my good friend Angela. You know, we partner on these things a lot. And we just see over and over again that when you have the integrated nonprofit health care system based in a community such as UPMC, and we have those members across the country, they're just approaching health care, including Medicare, in a different way.

And frankly, it's one of the great blessings of my job is that I'm getting to work with those really special mission-driven, community-based organizations that that have got their focus on the patient, the community, the partnership.

And I think that we're at an important time in health care because there are all those big challenges and big costs, but also the excitement of wonderful new therapies, wonderful new ways, as Angela said, to get care at home. And so those are the really exciting opportunities. And we just want to ensure that there's always going to be this good, healthy competition so we keep that up.

Ellen

Angela?

Angela

Well, it's my favorite topic of course. So, one of the things that I think is, is vitally important is for our seniors to really understand who their partner is in this Medicare Advantage space. We're very oriented around service, and really being almost servant leaders in this space. So, our customer service is award winning. It's really just an incredible group. We don't limit our teams and say, oh, you have to get people off the phone or you have to, you know, do things very quickly or anything. We want to respect and honor not just the time, but the value that our seniors place with us in choosing us.

So if they have a need and they call Member Services, they're going to speak to a friend and a neighbor. We are local. We are someone who really does focus on the needs of the community. And a lot of what we do, we don't put a lot of fanfare behind it necessarily, because we put everything back into, you know, our communities, into our teams, into our benefit designs.

We created programs that have a social need focus. So, for example, social transportation for some of our seniors to be able to go to church or their synagogue or their mosque, or to go to the grocery store. Many plans just allow for medical transportation. But we recognize that there's more to health than just the physician office. That's the kind of innovation that we're always thinking about.

And the last thing that I would say is, again, back to that access and affordability. There's a lot of questions around the supplemental benefits overall and what that means between traditional Medicare and Medicare Advantage. At UPMC, we're designing those supplemental benefits to allow for member choice.

We spend a lot of time thinking about, well, what are the kind of services and the benefits that our members need? I had a senior come up to me at one member meeting and he said, “Why are you putting limits on, you know, on my dental benefits or on anything?” And I said, “Well, part of it is affordability, but what is it that you're looking for?” And he said, “Well, yeah, I need to get my teeth cleaned every, you know, couple of months and stuff. But I don't always need a crown or something else. And so why can't I spend those dollars on hearing aids or glasses or something else?” And I said, “You know, that's a really good question and a really good thought.”

So, we challenge our teams to think outside the box a bit, and we still have our traditional benefits from, you know, in the supplemental benefits space of dental, vision, and hearing. But we created a different model where they could use other dollars through their Flex Card however they wanted, you know, based on what they needed for that year. We allow for food services and other things when you're coming out of the hospital.

And above all else, we coordinate care. Not all of our physician and specialist friends and partners talk to each other all the time. And that can sometimes be challenging, especially when you're vulnerable, when you're in the hospital or coming out of it. And many people are on more than one medication. And when there's changes that take place, you want someone who's going to help you navigate through. Somebody you can ask questions of if your physicians aren't always readily available. Because now, again, in this post-pandemic space, there's a lot of challenges to access because the needs are so great. And we'll come through that and there's going to be a rebalancing. But in the meantime, and as we go, the great thing about UPMC is that we stay focused on you. We stay focused on that service mindset, being those good stewards of those public dollars that you've trusted us with, and really focusing on quality and care and investing back in the things that our members tell us that they want and need and making that intentional in our benefits.

Ellen
It sounds like southwestern Pennsylvania is a good place to be in the market for a Medicare Advantage plan—and that it is an interesting, challenging, but really exciting time to be working in the Medicare Advantage space. So really grateful to both of you for taking the time to talk with us on “Good Health, Better World.

Ceci, thank you for joining us

Ceci

My pleasure.

Ellen

Angela, thanks for joining us. And thanks for everything you and your teams are doing to support our Medicare Advantage members.

Angela

Oh, well thank you. It's a pleasure and a blessing and a gift.

Ellen

We hope you enjoyed this episode of “Good Health, Better World.” Be sure to tune in next time and visit upmchealthplan.com/goodhealth for resources and show notes.

This podcast is for informational and educational purposes. It is not medical care or advice. Individuals in need of medical care should consult their care provider. Views and opinions expressed by the host and guests are solely their own and do not necessarily reflect those of UPMC Health Plan and its employees.

Guest Speakers:

Angela Perri

Chief Medicare Officer, UPMC Health Plan

Adjunct Professor, University of Pittsburgh School of Public Health

Angela L. Perri leads the Health Plan’s Medicare Products division, which includes the Medicare Advantage and Special Needs Plans (SNP) known as UPMC for Life. She provides strategic direction for the Medicare-SNP products focused on serving all seniors, persons with disabilities, and those who are dually eligible for Medicare and Medicaid.

Angela has nearly 25 years of experience in managed health care and managed behavioral health care. Prior to joining UPMC Health Plan, she served in executive leadership roles for several Fortune 100 organizations including UnitedHealth Group (Optum), Centene Corporation, and Amerigroup (an Anthem Company).

She is recognized as an expert on population health program designs such as models of care for Persons with Intellectual and Developmental Disabilities (IDD), Foster Care (children), Managed Long Term Services and Supports (LTSS) and integrated behavioral health, digital and technology solutions supporting strategies for value-based care and other innovations. She is passionately committed to serving the underserved in health care and education.

Ceci Connolly

President and CEO, Alliance of Community Health Plans

Ceci Connolly is a nationally recognized thought leader, author, and chief executive officer of the Alliance of Community Health Plans (ACHP). But if you refer to her as a former ink-stained wretch, she won’t object. Ceci spent 25 years in the news business, covering politics and health care, including 13 years at the Washington Post. She is co-author of Landmark: America's New Health Care Law and What It Means for Us All. Between her journalism career and ACHP, she worked at McKinsey and PwC, concluding that fee-for-service medicine is what ails us. Her passion now is to put a stake in it. She is a founding member of Women of Impact, serves on the Board of the Pharmacy Quality Alliance, and is a previous Board member of Whitman-Walker Health. She hosts the “Healthy Dialogue” podcast and is a guest host for “Her Story.” Ceci was the first nonphysician to receive the Mayo Clinic Plummer Society Award for promoting deeper understanding of science and medicine. She remains an adrenaline junkie and stickler for good grammar.