Medicare Advantage plan representatives' perspectives on Pay for Success

Area of Science:

• Health Services Research
• Health Policy
• Social Determinants of Health

Background:

• Medicare Advantage (MA) plans are increasingly focused on addressing members' social determinants of health.
• Alternative financing models like Pay for Success (PFS) offer potential solutions for funding these initiatives.
• Understanding MA plan representatives' perspectives on PFS is crucial for its successful implementation.

Purpose of the Study:

• To explore Medicare Advantage plan representatives' perceptions of the Pay for Success (PFS) financing model.
• To assess the potential of PFS to address social risk factors among MA members.
• To understand barriers and facilitators to implementing PFS within MA plans.

Main Methods:

• Qualitative study employing semistructured interviews with 38 upper-management representatives from 17 MA plans.
• Interviews focused on priorities for addressing nonmedical needs, awareness of PFS, and implementation considerations.
• Thematic analysis of interview transcripts to identify overarching themes and patterns.

Main Results:

• MA plan representatives generally lacked familiarity with PFS but expressed interest in its application to social needs.
• Responses regarding data sharing and performance evaluation varied, with some preferring internal processes.
• While innovation was a priority for many, some representatives favored traditional service delivery methods due to risk aversion.

Conclusions:

• MA plan representatives are largely unfamiliar with PFS but show interest in its potential for innovative social needs programming.
• Educational initiatives are needed to increase MA representatives' understanding of PFS as an alternative payment model.
• Further guidance from the Centers for Medicare & Medicaid Services (CMS) is necessary to address concerns and facilitate PFS adoption.