Lessons learned from operating Medicare Advantage Clinics (MACs)

Understanding the nuances, operational challenges, and strategies of Medicare Advantage Clinics (MACs) has become increasingly important.  

In 2023, over 28 million beneficiaries were enrolled in Medicare Advantage plans. Thousands of providers and health systems across the country participate in these plans, and are informally recognized as "MACS.”

For healthcare leaders, operational decisions and their nuances have exponential impacts on patient care and reimbursements. This blog post explores the challenges MACs face and the opportunities afforded by AI and automation to address these challenges.  

Operational challenges 

1. Patient acquisition

One of the primary challenges for MACs is attracting new patients. Many existing Medicare patients have established relationships with primary care providers and are reluctant to switch. 

2. Financial viability

Another significant hurdle is maintaining profitability while serving a complex patient population. Providers often request smaller patient panels to ensure quality of care. However, if panels become too small, revenue diminishes. 

3. Staffing complexity

Given their patients' high prevalence of chronic conditions, MACs typically require a larger staffing infrastructure to execute care plans and coordinate services effectively. However, this can strain resources and complicate operational management.

The opportunity for AI and automation

1. Enhanced patient outreach and engagement

AI Agents can significantly streamline patient acquisition. By utilizing data from health plans, clinics can employ automated outreach methods—such as email, text messages, and AI-driven voice calls—to connect with a larger patient base than traditional methods allow.

2. Improved value based care staff and provider workflows 

AI Agents have demonstrated tremendous success in automating administrative workflows. For example, Notable’s AI Agents provide intelligent chart summaries by scouring through faxes, PDFs, chart notes, lab, medications, and more to produce a concise patient history, which can be used to prepare for a visit and help populate a provider’s note.  

AI Agents can also provide structured and unstructured data, and generate evidence for Hierarchical Condition Categories (HCC). This reduces the need for the provider to comb through pages and pages to update his or her problem list. 

This technology can also update and close care gaps by sending reminders directly to patients scheduling appointments automatically without requiring clinic staff to intervene. Additionally, many care gaps are actually completed by the patient, but perhaps not in the native EMR of the primary care provider and show up by way of a fax or a scanned document.  AI can read those documents, bring back those data, and submit the information directly to the payer to ensure appropriate accounting is complete. All of this enables providers to focus more on patient care and less on administrative tasks.

3. Automated care plan execution and care coordination

Care plans are often complex and involve multiple interventions, specialists, and healthcare settings. Ensuring that all components of a care plan are followed accurately can be difficult, particularly for patients with multiple comorbidities. This is an opportunity for AI.

Notable’s AI Agents can take on tasks like reviewing a clinician’s care plan and sending follow-up messages directly from the care plan. For example, a provider orders lab work, but who ensures the patient goes and gets the lab work done? AI can send a message or call directly after a visit, bridging the gap between patient and provider without additional strain on clinic staff.

Actionable advice for healthcare leaders 

1. Expand panel sizes: Growth is necessary to effectively serve the burgeoning Medicare population. By leveraging AI and automation, clinics can engage a larger patient base while maintaining care quality. It is also required to maintain financial viability for MACs who may not have extremely high RAF scores. 

2. Enhance patient engagement: Use AI for routine wellness checks through periodic messaging, freeing clinicians to focus on complex cases while ensuring patients feel supported.

3. Streamline access: Address the cultural tendencies of patients who default to emergency care for minor issues. By providing easier access to primary care through various scheduling channels, clinics can reduce unnecessary emergency department visits.

4. Utilize risk prediction algorithms: Identify at-risk patients using predictive analytics, which allows for timely interventions that can prevent costly health service utilization.

Conclusion

The operation of Medicare Advantage Clinics (MACs) presents unique challenges and significant opportunities. By integrating AI and automation, MACs can streamline operations, enhance patient care, and ultimately achieve greater financial stability. As the healthcare landscape continues to change, adapting to these innovations will be key for MAC leaders seeking to navigate the complexities of care for Medicare beneficiaries. Embracing these practices will improve patient outcomes and ensure the sustainability and growth of MACs in an increasingly competitive environment.

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