In this business profile, Gene Cronin, vice president for Priority Advantage, discusses the value and benefits of working with a top-notch Medicare Advantage service vendor.

Gene CroninTell us a little bit about your organization.

Priority Advantage LLC is a strategic business unit of Priority Health—one of the nation's leading provider-sponsored health plans, headquartered in Grand Rapids, Mich. Priority Advantage offers front-, mid-, and back-office services—both end-to-end and point solutions—to help health systems and health plans start and effectively manage a Medicare Advantage (MA) plan.

More specifically, Priority Advantage is a services partner for health systems or health plans looking to enter the MA market, or for existing MA plans wanting to improve their performance and capture greater system or plan value. Our model is built on the experience and insight gained from operating Priority Health Medicare, which covers more than 140,000 lives and is the fastest-growing MA plan in the "More than 50,000 lives" category.

Priority Health Medicare has consistently been a top-performing MA plan in Michigan, as well as nationally. It is the fourth-largest provider-sponsored plan in the United States and ranks among the top plans in terms of membership and revenue growth, quality, and cost management. Priority Advantage leverages the expertise of Priority Health to provide a full suite of administrative services to help other organizations achieve success. As a partner with a proven track record, we will not only ensure you maximize value capture, but get there quickly.

What are some of the biggest challenges you see affecting healthcare organizations?

The industry faces continuing pressure to control costs and improve patient health outcomes. The regulatory environment and new payment models that reward value versus volume—potentially squeezing reimbursement rates—along with the ongoing trend toward market consolidation, will continue to force health systems and health plans to seek ways to grow market share, identify alternative revenue sources, and enhance value capture. Within this demanding environment, organizations are also having to control costs and deliver high-quality patient care. Without the right partner, this can lead to a multitude of competing priorities, which can quickly overwhelm an already busy healthcare organization.

How does your product or service offering address these challenges?

Due to the market, revenue, and profit growth forecast for Medicare Advantage during the next five to 10 years, these types of plans represent a tremendous strategic opportunity for health systems and health plans to diversify revenue, grow market share, and capture more value.

Many organizations recognize this opportunity and are exploring ways to enter the MA marketplace. Some think the best approach is to build an in-house MA plan from the ground up. However, that can delay an organization from getting the plan to market, or, more importantly, it can lead to launching a plan without a complete understanding of the requirements for success—resulting in poor performance.

Building an MA plan is complex, and merely having one isn't enough: The plan must be high-performing to achieve maximum value. High-performing plans generate as much as 12 times the value of average plans, and low-performing plans can be a financial strain.

By working with a company like ours, which already has a high-performing plan in place, organizations can take advantage of our blueprint for success. We can help you execute multiple key capabilities across the value chain, such as market assessment; product design and pricing; risk adjustment; quality; compliance; and more.

Operationalization can be difficult if an organization lacks MA knowledge and insight. By not working with a proven partner, it will take time to build an MA plan, and it may be difficult—if not impossible—to quickly achieve the necessary expertise to deliver above-average performance. Note that numerous low-performing plans are exiting the market or paying penalties to the Centers for Medicare & Medicaid Services (CMS). In addition, if an organization is performing at 3.5 stars or below, it may not be reaping the benefits of an MA plan. In fact, it is likely losing money.

Are there key product/service features that people should know about?

To be successful in Medicare Advantage, you must be able to execute on key capabilities across the value chain. Priority Advantage helps partners sustain high performance in essential functions because we do it ourselves every day in the Priority Health Medicare plan.

Conversely, there are several vendors in the market today that have strengths in one or two areas and select other vendors to deliver on different capabilities. In these cases, what they're selling is not their ability to perform across MA functions, but their vendor-management skills.

What advice would you offer to healthcare leaders when choosing among vendors?

First and foremost, you should determine your objectives and decide which prospective partners are best positioned to help you achieve them. It's also important to choose a partner with a proven track record of performance. There are Medicare services vendors that started their businesses not because they were looking to leverage demonstrated, industry-leading capabilities, but because they saw a market opportunity. Although it's beneficial for them, this may not necessarily translate into good results for you. There are other vendors who have years of MA market experience but may not have stellar performance. Make sure your potential partner doesn't just have average outcomes or is only strong in one area. Double-check that it has demonstrated excellence in launching an MA plan and providing exemplary, end-to-end functionality.

Another thing to ask is how much risk a potential partner is willing to assume. If it's claiming it can help you achieve high performance, then it should be willing to stand behind that claim by putting its own dollars at risk.

As healthcare organizations implement use of your product or service into their day-to-day operations, what advice would you offer so they can best set themselves up for success?

Understand that this is a partnership. Although outsourcing services to the right partner will help you accelerate MA plan performance and value capture, you can't simply hand over your business to a vendor and expect success.

The right partner will help you navigate the market and avoid pitfalls to achieve high performance, but, more importantly, it will work with you to integrate your MA plan into your broader system strategy. Also, a strong vendor will help you identify and leverage the strengths you've developed to further improve organization-wide results.

Are there any educational materials you would like to share to help healthcare providers in these efforts?

The Boston Consulting Group recently published a white paper examining what it takes to be a high-performing MA plan. It reinforces that choosing the right partner is critical to MA market success and highlights Priority Health as an example of an MA organization that has achieved great success. 

Priority Advantage is a private label, end-to-end solution that helps health systems and plans thrive in the senior market. Powered by the fastest-growing plan in the country—Priority Health Medicare—Priority Advantage applies industry expertise, comprehensive support, and an enterprising approach to build a successful Medicare Advantage product. Priority Advantage's practitioners help identify opportunities for growth and performance to deliver powerful results. For more information, visit priorityadvantage.com.


priority-advantage-logoContent for this Business Profile is supplied by Priority Advantage. This published piece is provided for advertisement purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions of those profiled are those of the individual and not those of HFMA. References to commercial manufacturers, vendors, products, or services that appear do not constitute endorsement by HFMA.   

Publication Date: Monday, July 31, 2017