The healthcare industry is undergoing significant transformations, with various trends shaping the future of Medicare and post-acute care. As projected by the Centers for Medicare & Medicaid Services (CMS), Medicare spending is expected to experience rapid growth, making it the fastest among major payers. By 2028, it is estimated that over one-fifth of the population, or 75 million individuals, will be enrolled in the Medicare program.

A key driver of this growth is the increasing number of individuals transitioning from private health insurance into Medicare. This shift, along with CMS rate increases and subsidies, has led to a surge in the number of Medicare Advantage (MA) plan enrollees. The Congressional Budget Office (CBO) predicts that the share of all Medicare beneficiaries enrolled in MA plans could reach 61 percent by 2032, or even higher according to other sources. This shift is attributed to the lower premiums and enhanced benefits offered by MA plans compared to traditional Medicare.

Although CMS has not mandated the transition to MA plans, they have implemented changes and incentives to encourage MA enrollment and value-based care. CMS aims to establish an accountable care relationship between Medicare enrollees and healthcare providers by 2030. Additionally, the MA Value-Based Insurance Design Model has been extended to test innovations that decrease expenditures and improve quality. CMS has also introduced the health equity index (HEI) reward to enhance care for enrollees with social risk factors.

Furthermore, Medicaid lives are expected to remain predominantly members of managed care organizations, accounting for 72% of all Medicaid beneficiaries. Projected Medicaid spending growth is slightly higher, at 5.8 percent on average over 2024-28, due to factors such as the expiration of reductions to disproportionate share hospital payments and an increasing share of aged and disabled beneficiaries.

As the baby-boom cohort ages, with approximately 9 million Americans over the age of 85 by 2030, payers must seek innovative strategies to effectively manage these populations and remain competitive.

One critical area of focus for payers is managing post-acute care costs. Post-acute care accounts for about $60 billion, or 15%, of annual Medicare spending and continues to rise. Care coordination failures contribute to up to $78 billion in waste each year. However, the demand for post-acute care is outpacing availability, leading to longer acute lengths of stay and increasing challenges in home health referrals. Finding solutions that lower readmissions and reduce costs remains a significant challenge for payers.

The four major segments of post-acute care include Skilled Nursing Facilities, Home Health, Long Term Acute Care, and Inpatient Rehabilitation. Home health services are projected to experience the most substantial growth due to their affordability compared to other post-acute care options.

Looking ahead, the shift toward providing healthcare services in the home environment presents a promising opportunity. Over the next five years, an estimated $265 billion worth of healthcare services could be provided at home through innovations such as dialysis, telehealth, and remote patient monitoring. This shift to "Post-Acute 2.0" holds significant value for payers as they manage the increasing population of individuals requiring care.

In light of changing family structures and smaller family sizes, the demand for community support services is growing. People receiving post-acute home care often require additional resources such as meal delivery services, cancer support services navigation, transportation, and other social needs.

In conclusion, the healthcare landscape is rapidly evolving, impacting Medicare and post-acute care. Medicare spending is on the rise, with a growing number of individuals enrolling in Medicare Advantage plans. Effective management of post-acute care costs and the emergence of home-based care present opportunities for payers to adapt and innovate, ultimately improving the overall quality of care and outcomes for Medicare beneficiaries. By embracing these trends and investing in value-based models, payers can navigate the changing healthcare landscape successfully and meet the needs of the growing population in a cost-effective and patient-centric manner.