Myth-Busting: Are Medicare Advantage Seniors Embracing Virtual Care?

Welcome to Architect Health’s The Front Door Newsletter! In this newsletter, Architect Health’s Co-founder & CEO, Sohum Shah, interviews healthcare executives, founders, and experts on healthcare innovation, digital health, and preventative care. The goal is to identify pain points in these spaces and paint visions on how to address them, inspiring decision makers at traditional healthcare organizations.

Today’s interview features health plan executive, Dr. Darren Wethers. Dr. Wethers is Chief Medical Officer at ATRIO Health Plans, overseeing the plan's utilization management, care management, and pharmacy services. In this interview, Dr. Wethers discusses the advantages of a small regional health plan, the challenges of onboarding third-party vendors, and the new generation of tech-savvy seniors embracing telehealth.

As a reminder before we dive into the article: Architect Health is hosting a Healthcare Innovation Breakfast Panel for TechChicago Week featuring local healthcare leaders! If you’re in Chicago on July 26th, join us, here, alongside Drive Capital, Lightbank, J.P. Morgan, and Wilson Sonsini.

Listen to the Podcast:

• Spotify

• Spotify for Podcasters

• Apple

Darren Wethers, MD, CPE, is Chief Medical Officer of ATRIO Health Plans. He oversees the plan's utilization management, care management and pharmacy services and is the clinical liaison to the provider community. Prior to joining ATRIO, Dr. Wethers served as Vice President, Clinical Operations at Blue Cross Blue Shield of Arizona for 3 years and was the chief medical officer for BCBS Arizona Medicare Advantage plan for the preceding 4 years; he entered the payer space in 2011 as a Medical Director at Coventry Health Care and Aetna.

Dr. Wethers practiced internal medicine in the Midwest for more than 20 years, focused on HIV/AIDS and chemical dependency care; it was during this time that he became interested in administrative medicine as a career path. He earned his B.S in Biology at Morehouse College, Doctor of Medicine degree at Northwestern University in 1988, and completed internship and residency in Internal Medicine at Emory University. Dr. Wethers is board certified in internal medicine.

Takeaways from 2023

Sohum: What are your top three key takeaways on the healthcare landscape from 2023?

Dr. Wethers: In 2023, we saw a tremendous amount of Medicare Advantage growth. Members were drawn by a couple of things, one of which was the advancement of supplemental benefits, things like dental care, hearing aid assistance, meal plans. Members were also drawn by the maximum out of pocket protection that MA provides that traditional Medicare doesn't. The other thing that was really important was the emergence of biosimilar medications and specialty meds. Those are really driving the forefront of pharmacy development, and we're going to see that marketplace become more and more competitive.

Impact of the Pandemic on Digital Health

Sohum: As an insurer and physician, how has your view of digital health changed pre-pandemic versus post-pandemic?

Dr. Wethers: Pre-pandemic, I gave very little thought to telehealth. It was a tool that people in rural communities used to match people to specialists outside their service area. But in the pandemic, it became a tool that everyday people utilized, both in urban and rural communities. And in particular, we saw the emergence of behavioral health in the telehealth mode. I spoke recently to a good friend of mine who's a psychiatrist, and over 90% of his visits now are through telehealth. He rarely, if ever, goes to the office and prefers it that way. So I think that's a sign of things to come.

The other thing we've seen emerge are at home web enabled tools, anything from a simple blood pressure cuff to pulse oximeter cardiac monitoring that can be done in a remote fashion. As these gadgets become more commonplace, as the cost for them comes down, we'll probably see broader adoption and transformation in the way care is managed.

Long Term Strategy for Digital Health

Sohum: How does digital health fit into ATRIO’s long term mission? Were there any challenges you faced when determining your digital health strategy?

Dr. Wethers: About a year and a half ago, we started looking at contracting with a telehealth vendor, and heard presentations from a number of them, all very comprehensive. We selected one which we felt had breadth of service, especially in behavioral health, and was at a price point that we could manage as a small plan. If a health plan doesn't offer a comprehensive set of telehealth services, so the equivalent of urgent care, in some cases, longitudinal care management through virtual health, as well as disease specific things like diabetes management or high blood pressure management through virtual services, all of those have become commonplace and the norm.

Serving Tech-Savvy Seniors

Sohum: When people think about seniors on MA plans, they don't necessarily think tech savvy. Why do you believe in digital health and virtual care? What does a high performing and effective digital health ecosystem look like for you and your members?

Dr. Wethers: Today’s seniors who are aging into Medicare are different than the ones who preceded them ten years ago. They are far more tech savvy. They've come into their senior years having already used online services like online banking. They were part of the Facebook generation, and so they are very comfortable using tablets, laptops, desktop computers. I have an older sister who will qualify for Medicare this coming year, and so I know that she's representative of that generation. She can easily navigate a virtual world. So if she is an example, then all of the subsequent beneficiaries coming onto Medicare will bring that same comfort level with them, with an expectation that digital related services will be made available to them.

Point Solution Fatigue

Sohum: Concerns about point solution fatigue have been voiced by employers, health plans, and even patients. Is there a right or wrong when it comes to specialization of care for targeted populations? What novel approaches might you recommend to payers, employers and digital health providers combating this problem today?

Dr. Wethers: All of us have to listen to the patients about their expectations about when and how they’re communicated with. Is it through snail mail? Is it through text, through email? How many people are contacting them and at what times of day? At ATRIO, we employ vendors to help us with annual wellness visits and encourage people to close care gaps. But members reported back to us they didn't want to hear from external vendors. They expected to hear from the plan. So the more we're able to bring these services in house, the more our members will accept them.

We're working to improve our portal to show members what gaps in care remain for them or if they're due for a visit with their primary care doctor. If there are messages that we need to push, we can do it through the portal, but we need to make it fun and valuable for them to log on to the portal. We're not there now, but that's where we want to go. 

Leveraging AI for Payment Integrity

Sohum: Last year, ATRIO partnered with Health at Scale to leverage AI and machine learning technologies for payment integrity. What compelled ATRIO to utilize this innovative technology?

Dr. Wethers: Health at Scale reached out to us some time ago with a number of different platforms that they were offering. The one that caught my attention was their fraud, waste and abuse platform, which utilized AI to help identify suspicious patterns. And the way in which they communicated that back to the plan seemed to be really novel. So unlike our normal approaches, we didn't do an RFP or a much broader vetting, but instead just dove in with a pilot to see what we could learn.

It's my particular bias that a vendor such as that does not have approval or denial privileges. Those are the health plans. What they do is to refer things to us with recommendations. It's up to the plan to make a determination as to whether or not the recommendation has merit.

Onboarding Third-Party Platforms and Vendors

Sohum: What does the process of sourcing, vetting and onboarding external third party platforms and vendors look like? How should innovative companies approach plans today?

Dr. Wethers: Most often, if we're doing something on large scale, then we'll request a proposal document, and then we'll have a very detailed process for vetting the responses to the RFP document, from which we select finalists and then make a selection as to which of the organizations we would like to continue working with at larger health plans. Very often they'll have a contracting unit or a vendor management unit. We're too small for something like that. But in that scenario, there are very formal processes for vetting the contractor.

Advantages of Smaller Health Plans

Sohum: As a small health plan with around 30,000 members, what unique advantages does ATRIO have over larger national plans? How does this take forming community engagement, member navigation, external partnerships, and perhaps are there any disadvantages? 

Dr. Wethers: We’re small but nimble, able to make decisions without having to go through 75 layers of different authorization requirements. What sets us apart is that we tend to place service centers within the counties where we offer coverage. Members can walk into the service center, have questions answered, pay their premium, pick up materials related to their health care benefit. And that personal touch sets us apart from the multi state and multinational companies who often lack local presence.

Slowing Growth of Medicare

Sohum: A hot topic at the moment is the slowing growth of Medicare. Sign ups overall increased by 5.5% in 2023 versus 9% in 2022. As an MA plan, what are the underlying trends causing this shift? What are some of the growth levers ATRIO is pulling on to stimulate this market?

Dr. Wethers: Statistics can tell you different things. One I looked at said that over 50% of Medicare beneficiaries now are part of an MA plan. And so as more and more come into that marketplace, the rate of rise will probably fall, but the number of covered lives is going to increase. It doesn't mean that traditional Medicare is dead, but the advantages that MA provides become increasingly attractive to the members.

It's important for members to understand trade offs. If you come out of traditional Medicare, you will accept some limitations in the provider network. But in return, we're going to protect you against out-of-pocket costs that could run to infinity. We're going to protect you against predatory providers who might order things for you that aren’t medically appropriate. We're going to assure that you get standardized and recommended health screenings and immunizations. The data is clear that MA beneficiaries are more likely to get the recommended health screenings and immunizations than their counterparts in traditional Medicare. Those are all reasons why MA continues to grow. I expect to see that in our markets. Where we operate, MA is underpenetrated, so there's a lot of upside for us.

What’s Next for 2024?

Sohum: What are some changes or trends in healthcare you are most excited to witness for the rest of 2024?

Dr. Wethers: Gosh, good question. Earlier this year, we kicked off a utilization management committee, something new that CMS has demanded MA plans put in place. Most commercial plans already had them, but not all MA plans did, and to be quite candid, ATRIO did not.

Through this committee, we'll compile our physician reviewers, community physicians, and others within the health plan ecosystem to discuss how we're applying the benefits for our members. Making sure that we're aligning with the CMS requirements, being neither too punitive nor too permissive. Making sure that we have community physicians involved gives us the ear of that practicing doctor. We don't want to operate in isolation of those persons. Parallel with that, we have member councils in place so we can get the consumer’s voice. We want to provide care for, but also with the members and not be so top down.

There will also be more AI informed applications in the coming year. Where will that take us? Some expect AI to eliminate jobs. That may be in certain areas where there are repetitive tasks, where large amounts of data can be digested quickly. So we may see a reshifting and a rebalancing within the ranks of health care pay or employment.

Architect Health is a digital health aggregator, navigator, and vendor manager that makes it easy for health plans and their members to access virtual-first care solutions. Architect optimizes health plan RFP processes in a consolidated and comprehensive platform, reducing admin burden and costs. This helps health plans realize digital health cost savings opportunities - up to a 7x ROI. Architect's Digital Health Quality Index has vetted and scored thousands of telehealth solutions on efficacy, company reliability, and health equity. Co-founders Sohum Shah and Sidd Hariharan have deep expertise working with health plans and have built care management programs and aligned technology for Humana and BlueCross BlueShield. Architect Health is backed by Drive Capital, Entrepreneurs Roundtable Accelerator (ERA), Cherrystone Angel Group, Plug and Play Ventures, Service Provider Capital, and strategic advisors.

Follow us on LinkedIn and Twitter to keep up with the latest news!