By Tim
Mullaney | October 25, 2018 Courtesy Anthem
As senior living providers assess how they can
seize new opportunities in Medicare Advantage (MA), they should consider one of
the nation’s largest insurance companies an interested potential partner.
Indianapolis-based Anthem Inc. (NYSE: ANTM) is
the largest for-profit managed health company under the Blue Cross and Blue
Shield umbrella. It is also the most prominent insurer to announce benefits
packages created under newly relaxed Medicare Advantage rules, which allow for
coverage of non-skilled in-home care and other services.
The Centers for Medicare & Medicaid
Services (CMS) first announced this MA policy change last
April. In the months since, senior living operators have been contemplating
what the change could mean for them, because the newly allowed benefits cover
the sorts of services typically provided in settings like assisted living.
However, it’s been unclear how insurance companies that offer MA plans might
structure these benefits and when — and if — these insurers will start to offer
this type of coverage.
Anthem has been one of the first insurance
companies out the gate, announcing its new benefits packages in early October.
These benefits, which take effect in 2019, could be tapped by plan members
residing in senior living communities. And Anthem’s speed in bringing these new
offerings to market should be a signal to senior living providers that the
insurance company wants to be on the leading edge of innovation. As part of
that effort, Anthem is open to developing future benefits and business
arrangements that are more tailored specifically to the senior housing sector.
“It’s an open question for me, how do we work
with these facilities in the future?” Martin Esquivel, vice president of Medicare
product management at Anthem, told Senior Housing News. “Going forward, we want
to push the innovation buttons and see what we can do together.”
Anthem’s offering
The new benefits offered by Anthem-affiliated
health plans are branded “Essential Extras” in Georgia, Indiana, Kentucky,
Missouri, Ohio, Virginia and Wisconsin; “Everyday Extras” in Tennessee, Texas,
and New Jersey; and the new benefits are not branded in Anthem’s health plan
affiliates in California or Arizona. They cover services such as food delivery,
transportation, adult day center visits, installation of assistive devices in
the home, and up to 124 hours of in-home non-skilled care. Individuals enrolled
in plans with access to “Essential Extras” or “Everyday Extras” will need to
choose one of the services offered in the package.
“The reason we could jump so quickly [and
offer these benefits] is Anthem and its affiliated health plans are committed
to offering plans that offer high-quality medical care and other social and
support needs,” Esquivel said. “We had a list we were already contemplating,
and when the language came through, we were able to add to that list,
pressure-test it all, and identify the items we knew we could deliver.
Culturally, we were already there.”
MA insurers have multiple incentives for
offering these sorts of benefits. For one, they might build enrollment by
differentiating themselves from competing plans, and give consumers access to
services that they want. Insurers also could see bottom-line benefits through
better cost control. For example, by covering transportation and in-home
assistance with daily activities, Anthem might help prevent a beneficiary from
missing doctors’ appointments or experiencing a fall —- and this in turn should
cut down on costly hospital stays.
While the new benefits are most obviously
tailored to people who are not living in institutional settings, there are
certainly some MA beneficiaries who reside in independent living and assisted
living communities, Esquivel acknowledged. Anthem does not track the exact
number of its beneficiaries in senior living.
There might need to be some discussion among
senior living residents, Anthem representatives and leaders at the senior
living community about how to coordinate these newly covered services. For
example, an assisted living apartment probably already has grab-bars and
similar features installed, but a resident might tap the new MA benefit to get
a particular type of toilet seat, Esquivel said. Similarly, a senior living
community probably already provides some form of transportation, but a resident
might want to supplement that through the new MA coverage. And if there are
discussions to be had about residents using MA to pay for some services already
being offered in senior living settings, Anthem is also open to those
conversations.
“How do we innovate and leverage what [senior
living communities are] offering their consumers today?” Esquivel said. “It
could be as simple as a contracting arrangement where they bill [the insurer],
or something much more innovative that we haven’t thought of yet.”
Anthem may need to ‘get in line’
In light of expanding Medicare Advantage
benefits, it’s plausible that residents will be approaching senior living
providers and saying, “I’m getting this [service covered] through my MA plan,
so I shouldn’t have to pay for it out of pocket,” according to Anne Tumlinson,
founder and CEO of Washington, D.C.-based health care consultancy Anne
Tumlinson Innovations.
However, assisted living companies do not have
to quickly reassess their fee structures in response to this move by Anthem.
That’s because relatively few senior living
residents are enrolled in Medicare Advantage, Tumlinson told SHN. More
commonly, they are on Medicare fee-for-service and have some sort of
supplemental insurance.
Indeed, few residents of Juniper Communities
are MA beneficiaries, said Lynne Katzmann, founder and CEO of the Bloomfield,
New Jersey-based provider. However, she anticipates that many more residents
will enroll in Medicare Advantage in the coming years.
Part of this growth will be driven by efforts
like Anthem’s, she told SHN.
It’s a new development that these MA insurers
are so interested in working with senior housing, and it will likely lead to
partnerships of various kinds, in her opinion.
“I think these insurers have realized that
they want to grow their MA business, that senior housing has a built-in market,
and that if they can work out something with the senior housing provider, they
have access potentially to greater membership,” Katzmann said. “Should senior
housing providers do it? It can’t hurt to be affiliated with them.”
One big caveat, though, is that in working
with MA plans, senior living providers should negotiate hard so that they see
financial upside from the cost savings that they will be enabling the insurer
to achieve, she said. Senior living providers can drive this savings by keeping
beneficiaries healthier for longer periods of time, outside of hospitals and
other high-cost settings.
But both Katzmann and Tumlinson believe that
working with companies like Anthem is a limited opportunity for senior housing
providers. The new benefits that Anthem is offering won’t go very far in
serving a typical assisted living resident with multiple chronic conditions and
functional limitations, Katzmann pointed out.
A much larger opportunity is in senior housing
providers starting their own MA plans, she and Tumlinson argue. Some of the
nation’s largest operators have already done so, including Sunrise Senior
Living and Erickson Living. Katzmann is in the process of organizing a
consortium of providers to launch a plan.
“When senior housing operators who know these
individuals and can truly coordinate care and services are involved as the plan
sponsors, those benefits that could be provided under MA can go a lot further
in their impact on outcomes,” Katzmann said.
The senior living companies also are assured,
in this model, that they will reap financial benefits from the savings that the
plans achieve, and can see to it that proper reinvestments are made to
continually enhance services being provided to residents.
Tumlinson has only seen one example of an
independent MA plan willing to share enough of the premium dollar with a
long-term care provider to be competitive with the provider-led plans. If
Anthem or similar large insurance companies are serious about making further
inroads in senior housing, they will have to “get out of their own way” and
“get in line” behind the provider-led plans and some companies like Optum that are already
more deeply engaged in the sector, she said.
“That’s where I think all the innovation is
going to happen in senior living benefits, in the provider-led plans, where the
provider has skin in the game for the health care risk of their residents,”
Tumlinson said.
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