Hale, Not Frail: MA Set on Keeping the Elderly Fit

UnitedHealthcare has ditched Silver Sneakers for something it says is better. Other insurers are sticking with it. Either way, wellness is looming large in the MA market.

UnitedHealthcare garnered a lot of attention last December when it announced that it would drop Silver Sneakers as an offering in its Medicare Advantage (MA) plans in 2019. Steve Warner, who leads the UnitedHealthcare MA product team, did some PR damage control at the time. Warner told NPR that more than 90% of UnitedHealthcare’s policyholders who are eligible for Silver Sneakers (see “‘I Love It!'” on page 38) never set foot in a gym or use the benefit. Warner added that United wants to reach “a broader portion of our membership” with a “wider variety of fitness resources.”

Instead of Silver Sneakers, UnitedHealthcare’s MA and supplementary Medicare beneficiaries will get 50% off memberships in gyms, access to online wellness groups, and wellness coaches, reachable by phone. Its MA beneficiaries are also offered Renew Active, a UnitedHealthcare fitness program located at more than 7,000 sites.

United’s decision to end its partnership with Silver Sneakers and the subsequent fallout point to the new prominence wellness plays in MA plans. Many insurers are redesigning MA wellness programs, thanks to a policy change implemented last year by CMS that allows for the provision of daily maintenance care using nonskilled, in-home providers—the kind of services usually given in assisted living facilities.

Anthem, Cigna’s take

Anthem still offers Silver Sneakers in its MA and Medicare supplement benefit packages; Martin Esquivel makes sure of that. Esquivel, vice president of Medicare product management for Anthem, oversees strategy for that insurer’s MA plans. “That’s their [United’s] business decision [not to], but for us, access to a gym is important.” Anthem has more than 1. 7 million consumers in affiliated MA or Medicare supplement plans.

Esquivel says that utilization rates vary. “We’ve seen higher participation numbers in some markets where Silver Sneakers has been there longer or where there’s certainly more demand there than in others,” Esquivel says. Anthem uses its quarterly newsletter and other marketing materials to remind members of the Silver Sneakers benefit.

For its part, Cigna kinda sorta knows what United- Healthcare is experiencing, and United officials probably hope that it plays out the same way. Cigna’s Medicare Advantage product, Cigna-HealthSpring, stopped offering the fitness benefit through Silver Sneakers in 2015, and instead offered the fitness benefit through Silver & Fit. Silver & Fit was a hit from the start, offering customers a comparable fitness benefit, and Cigna-HealthSpring did not suffer from any adverse publicity.

“Silver & Fit is available in 90% of our plans,” says Brent J. Sanders, who oversees Cigna-HealthSpring. “Fitness is one of the most popular benefits we have for customers in our Medicare Advantage plans.”

When pressed for details about Silver & Fit, a Cigna spokesman said that it is very similar to Silver Sneakers. The Silver & Fit website says that members need only to enter their ZIP code to find the gym nearest them that participates in the Silver & Fit program. There are gender-specific facilities for those who so desire.

The gyms offer the basics: cardio and strength training. Classes in yoga and Zumba are also available. The very fit can go to exercise centers. Amenities may vary, but could include Pilates, sports fields or courts, and saunas.

UHC whistleblower

UnitedHealthcare declined numerous times to talk to MANAGED CARE. It was also mostly quiet in a long piece in the Feb. 4, 2019, issue of the New Yorker about Benjamin Poehling, a former United employeeturned- whistleblower about its allegedly fraudulent MA business practices.

Poehling seemed dubious (to say the least) that MA was working as intended and he told the New Yorker that “a lot of enrollees get free gym memberships, free dental care. They get all these things you don’t get with fee-for-service Medicare. When people say, ‘Well, how do these private companies do it, how do they fund it?’ Well, this is how they fund it!”

As the New Yorker mentions, UnitedHealthcare is “fighting vigorously” against the allegations in court. The magazine quotes a statement from a UnitedHealthcare spokesperson: “Our company followed the Medicare Advantage program rules and has been transparent with the government about our approach.” The spokesperson also pointed out that CMS “has continued to accept our bids and pays us under our contracts.”


Favorable selection no more?

There was a time when insurers were accused (often rightly) of using wellness to lure healthier beneficiaries into MA. Search the literature, and you’ll find plenty of studies that explore the issue of favorable risk selection in MA, such as one led by Joseph Newhouse that was published in the December 2012 issue of Health Affairs (“Steps To Reduce Favorable Risk Selection in Medicare Advantage Largely Succeeded, Boding Well for Health Insurance Exchanges”). Favorable selection has been less of an issue lately—and there’s good reason for that, according to Newhouse, a Harvard health policy professor.

Insurers may indeed want to favorably select, but it’s difficult, says Newhouse, since CMS implemented the hierarchical condition categories (HCC) system in the mid-aughts. HCC risk-adjusts payments made to MA plans. “If you go back before the mid-2000s, they did favorably select or were able to,” says Newhouse. “But there’s very little evidence of that now. And the other point to make is that their payment now for a given diagnosis relative to another diagnosis is based on what traditional Medicare spends for each diagnosis. That is to say the weights are approximately proportional.”

As Newhouse sees it, the issue is whether wellness benefits can help manage medical spending. “To the degree they do minimize medical spending, the beneficiaries will presumptively be better off healthwise,” says Newhouse.

Not just for the young

There’s been a societal viewpoint shift regarding wellness, and many elderly will not go gentle into that good night. Della Gehl, 82, and a Silver Sneakers member, says that when she was growing up fitness really wasn’t stressed, especially when people reached middle age.

“It wasn’t the thing it is now,” says Gehl, who lives in Manhattan. “Now, it’s so important.”

Newhouse may not be the best example, since he gets benefits through his employer, Harvard. But he does go to the gym. And, at 77, Newhouse has no plans to retire.

“I enjoy what I’m doing and I don’t know what I’d enjoy more if I stopped doing it,” says Newhouse.

‘I love it!’

Silver Sneakers gets her up and out the door

Silver Sneakers, an exercise program designed for older adults, is included in many MA plans. Membership includes access to more than 15,000 gyms and fitness centers across the country. Those who don’t want to go to a gym can take exercise classes at other community locations, such as rec centers, senior communities, and churches.

Founded in 1992, Silver Sneakers is the brainchild of a concerned daughter. Mary Swanson’s father survived a heart attack at age 51 and he decided to change his lifestyle, which included hitting the gym. His health improved dramatically. Silver Sneakers instructors have CPR certification; a two- or four-year degree in exercise science, health, recreation, or physical activity; and get Silver Sneakers training.

“Silver Sneakers is a large part of my life and I love it and I can’t imagine what I’d do without it,” says Della Gehl. She’s 82, lives in Manhattan, and has been a member of Silver Sneakers since 2012. The benefit is provided by her insurer, Empire Blue Cross Blue Shield, an Anthem affiliate.

Gehl used to go five times a week, but now it’s four because she audits a course on political theory at Hunter College. The gym sessions usually last either 25 or 55 minutes, depending on availability of space at the gyms Gehl goes to. That’s right, gyms.

“I go to three or four different places,” says Gehl, a mother of three, grandmother of four. “In Manhattan, we have so many different places to choose from. So, on different days I go to different places. One day you’ll be working on abs a lot. My favorite instructor works on balance. And I don’t like balance. It’s hard. And balance is what we need. You know, try to stand on one foot.”

She exercises with weights, from one to five pounds (she’s at four at the moment). Also, stretch bands and— she adds with a rueful chuckle—an exercise ball, “which is my least favorite event because I am not good with the ball because you have to toss it. And you have to catch it and everything. I’m not doing so well in that.”

But she is fit and socially engaged. Gehl says that she’s met many friends through Silver Sneakers. It gives her purpose. “When you retire or get older you’re afraid of being isolated and not having a place to go,” says Gehl. “I used to go to a class that starts at 10 o’clock. Well, that gets me up, dressed and out the door. It’s just like working, only better because it only lasts an hour. It’s so good for all of us.”