Enrollment in Medicare Advantage is expected to surpass 50% of the eligible Medicare population this year, and its rise has created new opportunities for experimentation and savings in senior care. An example of this is the rising demand for senior-focused primary care.
Radio Advisory's Rachel Woods sat down with experts Sebastian Beckmann and Elysia Culver to discuss the growing interest in senior-focused primary care and the opportunities and challenges it could present to stakeholders.
Read a lightly edited excerpt from the interview below and download the episode for the full conversation.
Rachel Woods: Why does it feel, at least to me, like everyone in the industry is talking about senior-focused primary care right now? This isn't actually a new idea, but it feels like that.
Elysia Culver: I don't think it is a new idea at all. Historically, senior-focused primary care has been looked at as a bit niche. It's been looked at that way because it's a little bit hard to scale and typically it's something that we've only seen disruptors do.
But now, I think we're seeing so much interest in senior-focused primary care because of the huge market shifts that we're seeing — so the demographic shift of more seniors — and I think tangential to this is the growing enrollment in Medicare Advantage. So we've been hearing everywhere in the news that enrollment in Medicare Advantage this year is going to reach upwards of 50%.
And I think it's these huge shifts that are really creating this interest and also a pressure around how we innovate care for our older adults.
Woods: I should also probably stop us here. What exactly do we mean when we say senior-focused primary care? That means something specific.
Culver: Senior-focused primary care is a care model that focuses on serving older adults in a team-based approach, and it considers the senior's physical, psychological, and social needs, you'll see a lot of definitions call this holistic care. And the goal of senior-focused primary care, I would say, is to really use this team-based approach to lower cost, improve outcomes, and also improve the care coordination of older adults.
Sebastian Beckmann: I think it's helpful to compare it to more traditional primary care. So, the things that I think are really different to Elysia's point, it's team-based, so you have a primary care physician who is quarterbacking, but you have a lot of different care team members who are actually providing the care in the moment. So that's care navigators, NPs, PAs, the whole suite of staff who are doing things for that patient, nutritionists, taking that more holistic approach.
The second thing that's different, is that the panel sizes are a lot smaller. So each physician is serving a smaller number of patients, which means that they and their care team can spend more time actually caring for those individuals, and as a result, are able to do that holistic care.
Woods: And that's because this care is targeted, not just at any person over the age of 65, it tends to be focused on folks that are sicker, that have multiple chronic conditions that need this holistic team-based care approach.
Beckmann: Yeah. And I think it's helpful here to maybe talk through an example. So this is almost a cliche, but one of the things we keep hearing about is this patient in Alabama who has multiple chronic conditions and doesn't have an air conditioning unit. That's clearly a health risk for that patient, but a traditional primary care won't pick up on that because there's no one doing a health visit.
If instead, they're in a senior-focused primary care model, the very first visit they'll have is with a nurse who's coming to see them at their home, who will look for those social determinants of health, identify that they don't have an air conditioning unit, set them up with an air conditioning unit, and then actually make that happen. So that's not something that can happen in traditional primary care, but it does happen in these senior focus models.
Woods: In what other ways would it feel different to be a patient receiving this specialized form of primary care? You pointed out this perfect example of meeting your nonclinical needs, not having an AC unit, but how else will it feel different from traditional Medicare?
Culver: Typically, it'll feel different for the patient in senior-focused primary care because the model's basically focusing on everything that older adults are asking for. So they're asking for more time with their doctor, they're asking for a better relationship with their doctor, they're asking for better health and wellness benefits, and this is something that this is going to be able to provide with them. And because of this too, I think that it increases the communication and navigation that the patient needs in navigating their sickness, their chronic health conditions, the complex healthcare environment, things like that.
Woods: It's obvious to me why patients would want this. But tell me why other stakeholders in healthcare are interested in senior-focused primary care?
Culver: In general, when we think of stakeholders, in this situation, I think of physician groups, health systems and startups as the predominant ones here. And I think that they're really showing increased interest in senior-focused primary care programs, partly because of the growing population and the Medicare Advantage enrollment, which I mentioned earlier. But also, I think that they see a real opportunity here to manage this population of older adults and to provide them better care.
Woods: We've been talking in this industry for a long time about baby boomers aging into Medicare, this growing senior population. Tell me why now we are seeing such a change in the level of interest in senior-focused primary care from seemingly everyone?
Beckmann: There are two trends. The first, let's come back to Medicare Advantage growth. That example of the patient in Alabama who needs an air conditioning unit, a fee-for-service primary care is getting paid $0 for that, so there's no financial incentive for them to participate in it. As a result, this only really works if you have patients covered by Medicare Advantage and who are in those value-based or capitated models. So Medicare Advantage expansion is one of the reasons that you see so much growth here.
The second trend is, there's a lot of interest from outside groups like private equity, like big disruptors like Amazon who are trying to figure out how do they get a part of the healthcare spend. And they see an opportunity in value-based care, which means they have to control primary care because that's where they see the opportunity to inflect downstream spending, which is where they think they can really make a difference on dollars. And it means that they're competing in an area that incumbents like health systems haven't been willing to play because health systems have a vested interest in keeping hospitalizations and post-acute utilization and so on.
Woods: I don't mean to be pessimistic in this moment, but I'm trying to understand what the downside is. Because what I'm hearing you say is that there is a business opportunity for a lot of different stakeholders in healthcare, and this is a healthcare business podcast. I am also hearing that this is a great option and a great model for seniors who aren't turning 65, they're turning 75 and they have multiple chronic conditions. Be honest with me, what is the downside?
Culver: I think that the biggest downside is probably the ability to scale this model and ability to scale the model given the size of the demographic shift. But I think when we talk about scale, it's important to talk about what we mean by that. And in this case, it means increasing membership to existing or new markets, increasing network partnerships, expanded services, or care delivery channels, and it also could mean increased margins or volumes. All of these things though, it's going to be hard to do.
Woods: Because there are so many seniors that are going to be aging into the potential population that could be using senior-focused primary care.
Beckmann: We actually ran the numbers on that and we estimate that there's just shy of 10 million Medicare advantage beneficiaries who could benefit from these kinds of models.
Woods: My god, so is part of the scale problem not having enough doctors, enough actual physicians to deliver this care?
Culver: We mentioned this at the beginning, but senior-focused primary care takes an interdisciplinary team-based approach, meaning that doctors aren't the only piece of the puzzle here. We have advanced practice providers, we have nurses, we have social workers, pharmacists, behavioral health therapists, all of these are really going to be needed in order to make this model work.
Beckmann: We also thought that the problem here is going to be physician shortage. Now, I've been on here before to talk about physician shortage, there's a lot of reasons that I'm skeptical about that concept in general, but we did think that was going to be the limiter.
When we actually ran the numbers based on the lower panel size for senior-focused primary care, we got to about 10,000 primary care physicians you need full-time working in senior-focused primary care in order to support that entire 10 million patients. That's a small minority of the total PCP supply.
So we actually don't think that physicians are going to prevent scale. But to Elysia's point, it's a care team model. And when we did that same math on APPs and outpatient care managers, we found that you'd need about a quarter of all of the APPs currently in primary care to shift over, and by the way, almost 100,000 outpatient care managers.
I don't know how many outpatient care managers there are because that's the kind of job that goes to Amazon. Those people can shift careers, and a lot of them leave healthcare when they leave their jobs, so it's hard for us to say what proportion of the workforce that even is.