Keeping Medicare Advantage members healthier longer

Jeff Fernandez, President, Medicare, Aetna, shares how primary care helps members stay healthier and makes care more affordable.

• Medicare Advantage simplifies health care by bringing medical, pharmacy and supplemental benefits together under one plan, creating a more coordinated approach to health care coverage, Jeff says.

• Aetna is improving access to primary care and affordability to better support Medicare Advantage members, including those managing chronic conditions.

• “We want to make sure that the plans and the care that [members] receive are affordable, and that they're affordable over time,” Jeff says.

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Big Questions Answered helps us understand important CVS Health initiatives by taking a closer look at new products, powerful innovations and the big changes the company is making to achieve its strategic imperatives and build a world of health around every consumer. The company's senior leaders answer big questions from host Matt McGuire.

Matt McGuire
Medicare Advantage enrollment has grown substantially since launching nearly 30 years ago. By bringing medical, pharmacy and supplemental benefits together under one plan, Medicare Advantage offers members a simpler, more coordinated approach to health care coverage.

On this episode of Big Questions Answered, we'll learn about how Aetna Medicare Advantage continually evolves to meet members' changing health needs, the steps Aetna it taking to make health care more affordable and the innovations that help members stay healthier longer.

Welcome to Big Questions Answered, a podcast that helps us understand the important initiatives at CVS Health. I’m Matt McGuire from the Enterprise Communications team. I’ll be your host as we dive into the latest developments, breakthroughs and innovations that are helping us achieve our ambition to become America’s most trusted health care company. Thanks for joining me today as we get our big questions answered.

Jeff Fernandez is our guest this month. He is the president of Medicare at Aetna. And he leads the strategy, operations, and growth of the Aetna Medicare Advantage business, helping ensure millions of members receive valuable benefits, strong clinical support, and a high-quality member experience.

Jeff, I’ve got to imagine this is one of your busier months. Thank you for taking the time to stop by.

Jeff Fernandez
Thanks, Matt. Thank you for having me. And yes, it's getting ready to be the kickoff of AEP [annual enrollment period]. So yes, we are. We have been quite busy, indeed.

Matt McGuire
So, Jeff, Aetna introduced its 2027 Medicare Advantage plans a couple of weeks ago at the start of Medicare annual enrollment period. What market insights informed these plans and how will they benefit our members?

Jeff Fernandez
So, Matt, every year we take a look at the different plans that we offer in every single county and state, and we review it. And I think one of the things that the strengths that come out from year to year is one is the stability of the benefit plans. We really try to make sure that we get into the consumers’ needs, assess them, and provide them a benefit package that meets those needs. That's number one. Number two, what you're seeing from Aetna is a really broad portfolio of products. You know, in years past, the industry would really consolidate around certain types of plans, but I think one of the strengths that Aetna brings is, you know, we have everything from a MedSup [Medicare Supplement plan] and a standalone PDP to a Medicare Advantage, PPO product. And the HMO products have gotten bigger as well. The offerings under the HMOs from the chronic special needs plans, which include cardiovascular disease, CHF [congestive heart failure], and diabetes, and it now includes our D-stims, which are growing.

So, I think from our perspective, the way we think about them is, you know, we have a
very strong portfolio. And why that's important is, you know, when you turn 65, you have certain needs. Again, back to the needs assessment. And what happens, of course, as we age, our needs change. And it's really important to us at Aetna that no matter where you are in your life, no matter what your needs are at any given point in time, we have a product that meets it, and that creates stability, that creates longevity. We don't just want one member for one year. We want one member forever. And a strong product portfolio is a key part of that. And the other part of the insights and how they benefit our members, when you think about access to care, a really important part of health care discussion today. But all the access in the world is useless if you can't afford it. And so when you think about the majority of our plans have zero co-pays for a primary care visit. So, there's no impediment for you to go and get that annual checkup. In fact, we have all zero co-pays on preventative services. So, there's no reason why we can't stay in tip-top shape by seeing our doctor or getting our lab works done, getting those checkups.

And then, really, the other thing too is, look, if you do have something wrong with you and you have a drug that's in our tier 1 formulary, it's $0 copay. So there's no impediment for you to actually get those drugs and then take them. So we really focus on that affordability piece and keeping those copays as low as possible are really, really important.

Matt McGuire
Addressing members’ needs, offering different coverage options, focusing on affordability — this all sounds great. So, earlier this month, the Centers for Medicare and Medicaid Services announced the 2027 Star Ratings. Jeff, what can you tell us about how Aetna performed?

Jeff Fernandez
Thanks, Matt. We have more than 69% of our members in our 2027 plans that rated four Stars or higher. With these results, we are among the 2027 Star Ratings leaders for large publicly traded companies. And I think it's really important too that, I mean, I know the headline is always about the Star Ratings themselves. But I think it's really important that people who are listening to this podcast understand what's underneath those Star Ratings themselves. There are a bunch of measures that bake into what makes a Star Rating. And on the clinical side, there's some really, really important ones I think your listeners should hear.

When you think about readmission rates. If you think about, you go to the hospital, the last thing you want to do is go back and have to return because something didn't go right. On the readmission, the 30-day readmission rate, Aetna scored a 4.7 out of five across our entire Medicare Advantage population. That is a phenomenal number. It's a phenomenal testament to our clinicians and the work they do to make sure that when people are discharged from the hospital, they stay home, they get the care they need, and they don't have to go back. Really, really proud of that. The other area on the clinical side that's really important, and it gets to some of the things, those smaller things that we talked about that help slow disease progression and keep people healthy over time relates to the HEDIS [Healthcare Effectiveness Data and Information Set] preventive measures. Again, these are the measures that bake into that overall Star Rating. We scored four and five Stars results on these measures, such as care for the older adults medication reviews and the functional status assessments. Why is that important? That's important because these are those little things that help drive better health. If we don't do these things, it's more likely that your chronic condition gets worse and all of a sudden you end up in an emergency room or worse yet, you end up in a hospital.

And then I think there's some other things about these Star Ratings I think that people don't realize is that there's some operational components to it that are equally important. Something that's basic that you might say, “Oh, of course, customer service answers my phone calls.” Well, we can't take that for granted either because CMS has secret shoppers who call up and they time us. They time how long it takes to answer the phone call. They time how long it takes to transfer even down to timing with the secret shoppers, the foreign language TTY transfers. So, every bit of our customer service organization is measured in time, and we have to deliver. Because what has happened is, in order to achieve five stars in any of these operational metrics, you have to be 100% every time. That is really hard to do in any business, in any industry to be 100%, 100% of the time, but that's exactly what we achieved and it's really an amazing testament to this organization.

Matt McGuire
That’s impressive and something to be proud of. So, Medicare Advantage has been around for nearly 30 years. Jeff, what do you see as the value proposition fueling its growth?

Jeff Fernandez
So, probably the single biggest thing that fuels the growth in MA is the all-in-one aspect of Medicare Advantage. So, if you remember prior to Medicare Advantage, you know, when you aged into Medicare, you had to buy a MedSup and then you had a Medicare supplement and then you had to buy a standalone Part D program to pay for your drugs. Well, Medicare Advantage brings all of that under one umbrella. So, you get your medical for your hospitalizations, for your physicians, for your prescription drugs, but also in addition, all of your supplementary benefits. So, think about your dental, your vision, your hearing, some plans, depending on where you live, have a transportation benefit, some of them have over-the-counter cards — so all those supplementary benefits with one card. And I think the ease and convenience of that makes it really appealing because you only have one company to call, you only have one card to manage, and it's all under the same name.

The second part is something that is not offered under the Medicare Supplement Program, which is the clinical coordination. I mentioned that as result of some of our fantastic quality measures under the Star Rating program. When you think about the nurses that we employ, that when you are discharged from the hospital, they are following up with you to make sure that that home health agency showed up when they said it. They are following up with you to make sure you got your prescriptions and if you have any issues, or if you need to be on mail order from a convenience perspective, so maybe you don't have access to regular transportation, and so it's better they be delivered. All those connectors really, really matter when it comes down to which plan you pick.

And I think the other thing too is the lower cost and the improved quality that the plan has delivered over those years. You know, because again, back to that affordability question, we want to make sure that the plans and the care that they receive are affordable and that they're affordable over time. And I think those three things in particular have really driven the, you know, I'm old enough that have been in this business long enough. It's amazing that we've crossed over the threshold that over 50% of seniors in America are now on a Medicare Advantage plan, which is a testament to the consumer-driven market that we operate in, that people are picking our plans, more and more every year.

Matt McGuire
And that is great to hear. So, Jeff, you have been in the industry for more than three decades. What have you learned from Medicare members that has changed the way you think about health care? And how has Aetna incorporated that into its plans?

Jeff Fernandez
Thanks, Matt. That's a great question, because this is the ultimate consumer question, right? Because everybody thinks, “Oh, health care is health care, everybody has the same needs.” But the reality is, seniors' needs are unique, especially when they're dealing with chronic diseases like diabetes or heart failure, something for which they have to take medication on a monthly or regular basis.

So, we really think about, you know, when we look at learnings every year, but one of the things that always jumps out at me is this question around access to care. And so we're doing a lot of work, really pushing the envelope, around the role primary care has in the health care sphere. I mean, it relates also to the insurance, right? So how do we align the incentives with primary care, so that they, that they, the members feel that primary care presence. Because if the primary care is always going to be their quarterback for their care and all of the things that they're dealing with, we got to make sure they have access to that. So, that focus around primary care has been a really big learning, and frankly, the value of primary care.

The second part is affordability. Some of the things, when you think about insurance, you think about the big things, right? Because what if I go to the hospital? What if I have to have a surgery? And those are really important that we should always focus on them. But even sometimes the smaller things can have a big impact and one you might not expect. And you think about the innovation that the plans have done around affordability of over-the-counter drugs, for example. In the past, well, you just have to go to the drugstore and buy them all and it was all out of pocket. But now you can use your over-the-counter card through the Aetna plans and get those same drugs, over-the-counter drugs or aspirin or vitamins, etc., right there on the same card.

And that helps with the affordability because the less money you have to spend on things like that, you're more likely to be able to afford your other prescription drugs that are just as important. So, it really creates a nice full circle of just the care continuum and the totality of somebody's needs that I think the plans have really, really gotten really good at addressing.

Matt McGuire
Jeff, you’ve mentioned affordability several times in this conversation. And it's on everyone's mind these days. What is Aetna doing to make health care more affordable for Medicare Advantage members?

Jeff Fernandez
So foremost, the most important thing is that we are aligning ourselves with value-based providers in the market. So, you think about, we just talked about primary care physicians. We also do work with specialists. We do work with health systems. And that work is so, so important because we're focused on things like, things we talked about in the Star Ratings — readmission rates, talked about screens, colorectal cancer screens, breast cancer screens. Those are all services that are done by our provider network. And so when we have a provider network that's built around the philosophy of, “Hey, we need to make sure the Aetna members, their patients get those screenings,” that's really important. And that's what the value-based is. And saying, hey, there are a lot of little things that lead up to somebody having an illness or a sickness or a need for a surgery. Well, what are the little things that we could do to try and prevent those things?

And if I had to really summarize it in one phrase, the focus that Aetna has today on helping make health care more affordable is slowing disease progression. And what I mean by that is every day in America, somebody is diagnosed as a chronic kidney disease stage one. And what ends up happening is as the kidneys fail, your stage goes up — two, three, four and then five. And then ultimately, what we see is people end up in an emergency room with end-stage renal disease, and they need a kidney transplant. The thing that is, I mean, it's obviously upsetting just to hear that. But the more upsetting thing to us is this is preventable. We know that the drivers of why kidneys fail. And we know where they can be best treated, both in the primary care office and a nephrologist office.

And so this goes back to what I was talking about earlier around value-based networks, making sure that we have doctors that are focusing on treating things like diabetes and high blood pressure and hypertension, so that these bigger things don't happen to us down the road that require much more difficult choices in surgeries and operations. And so we are really, really have a keen eye on this across the entire enterprise, frankly, from on the insurance side, on our primary care side, on our in-home side, our pharmacies.
and our pharmacists that work inside of the CVS Pharmacies, we're all rallying around this concept of connecting care in such a way that people don't end up with a surgery that it could have been avoided in the long term.

Matt McGuire
I love the way we’re connecting care to prevent complications and slow disease progression. So, Jeff, to close things out, what innovations are you most excited about when it comes to improving the Medicare Advantage experience for Aetna members?

Jeff Fernandez
So, one of the things that we kind of talked a little bit about this was the access to care and how we sometimes you can take for granted, “Wow, everybody has the same access to care.” And that's just not true. It could be a, it could be an economic one, affordability one, it could be a I-don't-live-by-a-clinic one, or it could be I kind of live by a clinic, but I don't have a car or transportation to get to it, so, I don't live on a bus line. I mean, you could go through the list of things on why people don't have the same or equal access to care.

One of the things that we've been working on with Signify, who is a company underneath the CVS umbrella, as is Aetna, that we work with on things called in-home assessments. And what Signify will do is send the clinician into the member's home. And in that assessment, they will do all the basic stuff you might expect, like check my blood pressure, review the medications that I'm taking. And really from that, from all the information that we gather, we have a better view of what's going on in that member's life, and how they're dealing with things that may have been ailments in their health that need addressing.

And one of the things that we've noticed too is that, actually, the members that have those in-home assessments, a higher percentage of them actually end up in their primary care office for treatment. Because I think what we have found over time is our clinicians are identifying people who have some needs that are not met. And if we can meet those needs by connecting the dots and helping them get an appointment, for example, the better off that member is going to be. And two other things, affordability, right? If I can address my health conditions in a primary care office, that's certainly going to be cheaper than if I've been admitted to the hospital. So, the cost of care becomes more affordable. But even more importantly, the bigger impact that we're aiming for is that slowing the disease progression issue that we talked about. If these things go left untreated, I always am going to end up in a worse spot than if somebody had intervened on my behalf. And that's really what we're trying to do with the Medicare Advantage program.

Matt McGuire
These program innovations sound like they’re helping a lot of people. Jeff, I’ve had a great time talking with you. Thank you very much for stopping by.

Jeff Fernandez
Thanks for having me.

Matt McGuire
And a big thanks to you for tuning in to this episode. Until next time, I'm Matt McGuire. I look forward to joining you again to get more big questions answered.