Inside WVU Medicine's internal Medicare Advantage strategy

When it comes to Medicare Advantage, Morgantown, W.Va.-based WVU Medicine has shifted to an internal strategy that is poised for growth, according to the organization's CEO.

WVU Medicine is the majority owner of Morgantown-based Peak Health, a health insurer and health insurance services company also owned by Huntington, W.Va.-based Marshall Health Network, and Winchester, Va.-based Valley Health. The company launched in 2023. 

Albert Wright Jr., president and CEO of WVU Medicine, referenced Peak Health as the biggest way the health system has changed in the last year.

"We launched our Medicare Advantage plan [through Peak Health], and we're processing claims directly in Epic," he told Becker's. "We're using the Epic tapestry module. And I think that's why I'd say that the biggest change for our organization is that you have a true mindset change when you move from fee-for-service to taking full risk, which is just different from being part of an accountable care organization or a value-based agreement. You start to think about everything you do as both the payer, provider."

The Medicare Advantage plan is currently offered in about 30 of 55 West Virginia counties. Mr. Wright expects that to expand to 43 counties next year, and then, over time, expand to the whole state.

"It really is a shift in mindset of, 'Hey, we're going to go all in and figure out how we keep patients in the lowest cost setting and as healthy as possible while maintaining financial viability as an organization," he said. "So that's really the journey we started and are excited about."

WVU Medicine has started this journey as a number of health systems are considering whether to drop Medicare Advantage plans, citing "onerous" authorization requirements and high denial rates. A report from the Healthcare Financial Management Association and Eliciting Insights, based on a survey of 135 health system CFOs conducted in January, found that 16% of health systems are planning to stop accepting at least one Medicare Advantage plan in the next two years. Another 45% reported considering the same but have not finalized a decision.

Mr. Wright acknowledged that health systems have struggled with Medicare Advantage plans that are through insurers outside of their organizations.

"You're seeing this because, historically, we all worked with regular Medicare, [and] now, as we've seen this rapid growth of Medicare Advantage, external Medicare Advantage, it has introduced a significant administrative burden into the healthcare system. Now prior authorizations, denials have made Medicare patients that are on external Medicare Advantage much more complicated than we've ever had to in the past. And there's price negotiation. So you're seeing some health systems and hospitals throw their hands up and say, 'Yeah, we're just not going to deal with this.'"

WVU Medicine has not had to drop any Medicare Advantage plans up to this point. However, the health system, over time, doesn't "want to work with 25 external Medicare Advantage plans. We probably want to work with three or four that we have good agreed upon relationships with," said Mr. Wright.

Meanwhile, with Peak Health, the health system remains focused on building out capabilities in processing claims in real time in Epic as well as interoperability between the clinical product and the Medicare Advantage product.

"At Peak Health, with all of the built in advantages we have with the electronic medical record, interoperability, treating Peak as a cost center, we should be able to do two things," Mr. Wright said. "A patient that has Peak Health Medicare Advantage should feel like they have a much easier time navigating the healthcare system than if they had a non-Peak Medicare Advantage product. [Also, for] our physicians that work with our Peak Medicare Advantage pay, having that interoperability and that alignment should feel like it is the easiest Medicare Advantage plan for them to work with."

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