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Leverage your OTC benefit to improve MA chronic disease outcomes

CMS regulations give insurers new opportunities to make the most of this benefit.

5 min read


Leverage your OTC benefit to improve MA chronic disease outcomes

Under recent CMS guideline changes, Medicare Advantage plans have an unprecedented ability to offer supplemental benefits that are not primarily health related to chronically ill enrollees, and to tailor those benefits to an enrollee’s specific needs and condition.

This gives plans the opportunity to use their over-the-counter (OTC) benefit in new ways that can have a positive impact, both for the member and the health plan, while also improving the member’s health care experience.

Research has already shown that every $1 spent on OTC products has resulted in more than $7 in savings in the US healthcare system. When plans make the most of this benefit for members with chronic disease, the payoff in terms of improved health and savings will be particularly significant. About 117 million people in the US have at least one chronic disease, with 75% of adults over 65 having multiple chronic diseases.

The health consequences of poor management

While it’s too early for plans to report on the health benefits of tailoring OTC benefits to specific populations, the potential impact becomes clear when looking at the prevalence of chronic disease in the MA population, as well as the effects of poor disease management. 

  • 57% of Medicare beneficiaries have high blood pressure1, which if not effectively controlled can lead to damage to the arteries, heart, brain, kidneys and eyes.
  • 41% of Medicare beneficiaries have high cholesterol, which can lead to carotid artery disease, coronary heart disease, peripheral artery disease and stroke.
  • 27% of Medicare beneficiaries have diabetes. Poorly managed diabetes can lead to heart disease, stroke, kidney disease, high blood pressure, eye damage and foot problems.
  • 12% of Medicare beneficiaries have COPD/emphysema. Patients with poorly managed COPD are likely to require hospitalization or emergency department visits.

Not only will poorly managed diseases result in complications and possibly worse health outcomes for patients, but they also bring financial consequences. For example, research shows the median cost of care for patients with poorly controlled diabetes outpaced those of patients with controlled diabetes by almost 43% in the 65- to 74-year-old age group, rising to a nearly 50% gap for those age 85 and up.

But plans can now help stem those costs and improve member health and self-management by offering an OTC benefit that is personalized to specific conditions. Simple items like diabetic socks and sugar-free cough syrup, when made accessible to patients, may incrementally improve health outcomes.

Tailored outreach and treatments

“The potential health benefits and savings from OTC products are obvious. Plans and their members have even more to gain by leveraging OTC offerings by focusing on populations with the highest need,” says Tom Pelegrin, senior vice president and chief revenue officer for Convey Health Solutions.

This includes not only members who are chronically ill, but also those who have had recent surgery or been discharged after other inpatient care. Further, for the elderly and homebound populations, there are product options within their OTC programs that can improve living conditions, such as fall prevention products, emergency response solutions and other safety devices.

Convey works with health plans to proactively reach out to these groups, offering appropriate products that can improve health outcomes as well as educating the members on how to effectively use them. The ideal OTC benefit solution also offers access to clinicians and specialists — such as certified diabetes educators or fall prevention specialists — to provide support and advice while the member is ordering OTC products.

Integrating the OTC benefit

“We are working with health plans today combining their claims, prescription and other clinical data to help identify and determine the best course of action for specific populations,” advises Jonathan Starr, executive vice president of Convey Health Solutions. Combining advanced technology and analytics with market leading OTC benefit administration services, Convey generates automated alerts to health plan teams for:

  • information on products to discuss with members who meet certain parameters
  • a risk of adverse drug interactions with a member’s current prescriptions
  • support for products related to a new prescription

Additional alerts can help health plans promote preventive measures, such as signaling the OTC provider and plan when members have not received their annual health assessment, or advising outreach specialists about plan offerings that would be beneficial to members.

Fully integrating OTC benefits also creates a positive experience for members that can increase their satisfaction with their coverage, Pelegrin says. “Plan members are very excited to know they have this free benefit, and plans can build on that excitement to ensure they take the necessary steps to manage their conditions and protect their health and quality of life.”

Convey Health Solutions focuses on building specific technologies and services that can uniquely meet the needs of government-sponsored health plans. Convey provides member management, supplemental benefit management and advisory solutions for the rapidly changing health care world. Learn more.


1. Medicare Beneficiaries at a Glance. Centers for Medicare & Medicaid Services. 2019 Edition.