The
push toward valued-based care and population health management has raised
visibility around nonmedical conditions that impact health outcomes.
June 13, 2018
Improving health outcomes using population health
strategies could get a major boost with a new Medicare Advantage rule taking
effect this week.
Payers will now be able to work with companies like Uber
or Lyft to provide transportation, for example, as part of a more complete set
of benefits for the quickly growing MA population.
CMS issued a final rule in
May giving MA plans more flexibility in determining the types of supplemental
benefits they can offer chronically ill enrollees, including nonmedical
benefits. The new policy, part of a broad 2019 Medicare payment rule, means
plans like UnitedHealthcare and Humana aren't harnessed to a set
palette of supplemental benefits for members with chronic conditions, but can
tailor them to the specific needs of individuals.
The rule could see an array of new benefits aimed at
improving health outcomes by addressing issues such as housing and food
insecurity, transportation and social isolation. Potential benefits include
ride-hailing services, home visits, nutritional support, air conditioners for
people with asthma, home renovations like grab bars and other accommodations to
prevent falls, and home health aides.
Providers have praised the expansion of benefits. “We now
have a funding stream effectively within Medicare Advantage around social
services,” Don Crane, president and CEO of America’s Physician Groups (APG),
told Healthcare Dive in an interview. He called the change a “necessary and
appropriate step” in managing chronic diseases.
The focus on social determinants of health and population
health management is part of the broader shift to value-based care and
reimbursement. Some providers, payers and employers already offer wellness and
prevention programs or free rides to cut down on patient no-shows.
Whether the CMS rule leads to wider adoption of
population health programs generally remains to be seen, but as a fast-growing
segment of the Medicare market, insurers and providers are likely to be
watching for any impact on access to care, outcomes and cost.
Currently, about 21 million Americans are enrolled in MA
plans — or a little more than a third of Medicare beneficiaries. However, L.E.K
Consulting predicts enrollment will jump to 38 million, or 50% of market
penetration, by 2025.
'Reasonable
expectation of improving health'
Under the bipartisan budget deal signed
by the president in February, Congress expanded supplemental benefits for the
chronically ill to include ones that “have a reasonable expectation of
improving or maintaining the health or overall function of the chronically ill
enrollee and may not be limited to being primarily health related benefits.”
The law also authorizes CMS to waive uniformity requirements, but only with
respect to supplemental benefits for enrollees with chronic conditions.
Uber and Lyft, both with active partnerships in healthcare,
say the new policy will help them expand their footprint.
“This guidance demonstrates how serious CMS is in giving
health plans the tools they need to address the social determinants of health —
of which transportation is foundational,” Lauren Belive, director of federal
government relations at Lyft, told Healthcare Dive via email. “This new
flexibility will allow us to partner even more dynamically with MA plans to not
just help seniors suffering from chronic health conditions get to their health
appointments, but to more broadly leverage our platform to remove
transportation barriers and encourage healthy and active living.”
Katherine Hempstead, senior adviser to the EVP at the
Robert Wood Johnson Foundation, agrees. “It fits into the overall trend toward
paying for value and thinking about the broader array of things in our living
conditions that affect our health,” she told Healthcare Dive. “There can
definitely be sort of an ROI in covering some of these things.”
Tackling
social determinants of health
Following CMS’ release of the rule, APG announced a
partnership with the nonprofit Partners in Care Foundation to offer their
patients new benefits enabled by the rule. With the new regulations, practices
with MA members will likely want to avail themselves of the opportunity to
expand benefits. The issue is whether to build the infrastructure for these
services in-house or contract them out. “Our agreement with Partners in Care
creates ready resources for members to use,” Crane said.
Integrated benefit network Solera Health also sees an
opportunity in CMS’ expansion of benefits. “We think it’s extremely significant
because it validates the realization that healthcare-related social
determinants of health can have an impact on peoples’ ability to maintain and
improve their health between doctor visits,” Brenda Schmidt, founder and CEO of
the Phoenix-based company, told Healthcare Dive.
Solera, which is helping administer the Medicare Diabetes
Prevention Program, recently announced a partnership with nonprofit Feeding
Americato address food insecurity. Among those who will benefit are
Solera’s 37 MA plans, representing about 13 million covered lives. The company
also serves about 6 million Medicaid beneficiaries and 40 million commercial
lives.
Solera has a similar partnership with the Food as
Medicine Coalition in California, which received a $64 million grant from
MediCal to document the impact from providing medically tailored meals for
3,000 people in California.
Food and other social services for the needy and elderly
have been around for a long time. Meals on Wheels, for example, brings healthy
food to homes and addresses social isolation and inability to get around. What
changed with the budget bill and the CHRONIC Care Act included
in it is that industry now has the opportunity to operationalize and monetize
these healthcare-related social supports so that there is a sustainable revenue
model for organizations that typically have been philanthropically funded or
grant-supported, Schmidt says.
At the same time, it increases visibility at the member
level around who is receiving services so plans can document quality and cost.
This, in turn, provides a big opportunity for a new model
in healthcare, Schmidt says. “These highly disparate, highly fragmented
nonmedical social services really have never been integrated into healthcare
and require a business model that’s going to help health plans feel comfortable
with the quality and regulatory compliance of this class of providers,” she
says.
Insurers that Healthcare Dive reached out to did not say
whether or what new benefits they may offer next year. However, Sarah Bearce,
spokeswoman for UnitedHealthcare, said via email that “Medicare benefits should
not be one-size-fits-all, and continued rate stability and greater benefit
design flexibility enable health plans to provide a more personalized
healthcare experience for the millions of people who choose Medicare
Advantage."
While the new flexibility provides a lot of room for
innovation, it could also be a slippery slope. “You have to think about what’s
the limit to this,” Hempstead says. “On the one hand, you can reduce healthcare
costs by making sure people have all these other things covered. On the other
hand, you might think, wow, everything in the healthcare system is so
expensive. To what extent do we want to bring all these things into the
healthcare system?”
Plans need to carefully think about how they price these
new benefits and how much the system is paying for them so patients get
benefits without making everything cost more, she added. “I think there will be
a lot to learn about what is a good investment and what is not.”
An
unintended victim?
One potential victim of expanding MA benefits is the
long-term care insurance market. The number of people purchasing LTC
plans dropped nearly 14% from
2015 to 2016 — an eight-fold decline from the market’s peak in 2002. Earlier
this year, a major carrier went belly up,
forcing other carriers to pay into its guaranty fund. Carriers have complained
that they are underpriced and that people are staying in policies longer than
expected, with fewer lapses and higher claims than expected.
With an average annual premium of $3,490 for
a 60-year-old couple, many seniors may choose to switch to MA plans now that
they can provide some of the same benefits around daily living and home health
aides.
“It will be interesting to see to what extent this
partially solves the long-term care problem, because right now Medicare doesn’t
cover that stuff, so people either buy long-term care insurance, they use their
private savings or they end up kind of spending down and using Medicare,"
Hempstead says.
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