Supplemental
Benefits Never Sounded So Good
Naveen Rao Feb 10, 2019
Starting in 2020, Medicare
Advantage plans will be allowed to offer supplemental, “non-primarily
health-related” benefits to help certain eligible chronically ill patients with
unmet social needs. Put simply, this represents a large source of reimbursement
for social determinants of health (SDOH) solutions in the high-growth MA
market.
While this represents a real
opportunity for SDOH innovators, we are at an early stage of the rulemaking
process where there are far more questions than answers. The Centers for
Medicare and Medicaid Services (CMS) recently issued a draft CY 2020 Call Letter that provides guidance on
the new rules.
Making the Sausage: MA + SDOH
= SSBCI
There are actually two new, and
slightly different updates to the supplemental benefits provision under MA. In
2018, CMS announced they would expand reimbursements starting this year (2019)
in the MA program for non-clinical supports that promote the health of
chronically ill beneficiaries who meet certain eligibility criteria.
Importantly, this 2019 update does
not directly authorize benefits that address broader SDOH. The 2019 expansion
will be focused tightly on “primarily health-related benefits” like adult day
care, caregiver support, in-home supports, home safety modifications and more.
The bill did however, relax the
program’s “uniformity requirements” to allow more customized services not only
by diagnosis, but also by health status. For certain beneficiaries with complex
needs this could include “Z codes” in ICD-10 that document
non-clinical needs, such as assistance with self-care, living alone, or living
with a dependent relative.
The bigger news for SDOH innovators
starts in 2020, and comes with a fun new acronym for your deck of flashcards:
SSBCI.
Introducing: Special Supplemental
Benefits for the Chronically Ill (SSBCI)
Starting in 2020, SSBCI will amend
the 2019 requirements to encompass “supplemental benefits that are not
primarily health related and/or offered non-uniformly to eligible chronically
ill enrollees […] if certain conditions are met.”
The new outlook for SSBCI, albeit
from early on in the rule-making process, appears to offer a broad, flexible
set of conditions for innovators and health plans to explore product/market
fits for new approaches to address the SDOH. It’s not quite a blank canvas, so
let’s take a look at the policy more closely to get a better sense of the
business opportunity here.
Product: What Counts as
an SSBCI?
If you’re wondering what “not
primarily health related” jargon means in plain English, CMS’s explanation may
not help:
“MA plans will have the ability to
offer a “non-primarily health related” item or service to chronically ill
enrollees if the SSBCI has a reasonable expectation of improving
or maintaining the health or overall function of the enrollee as it
relates to the chronic disease.” (note: this is CMS’s emphasis, not our
own 🤔)
Examples of what SSBCI could be: “Such
items and services may include, but are not limited to, transportation for
non-medical needs, home-delivered meals (beyond the current allowable limited
basis), food and produce.”
Examples of what SSBCI cannot be: “capital
or structural improvements to the home of the enrollee that could potentially
increase property value (e.g., permanent ramps, and widening hallways or
doorways)…Additionally, items and services may not be offered to induce
enrollment.”
Examples of what SSBCI maybe could
be but only time will tell: More broadly, this new ruling has been intentionally
designed to provide plans with “broad discretion” — might we see dollars open
up for peer supports, CHW, culturally tailored services, financial assistance,
or even pet therapy?
Market: Which Beneficiaries (and
How Many) are Eligible?
If defining what will be paid for
is one key variable in this equation, then the other is defining who is
eligible. From the regulation:
“Section 1852(a)(3)(D)(ii), as
amended, defines a chronically ill enrollee as an individual who:
1) has one or more comorbid and
medically complex chronic conditions that is life threatening or significantly
limits the overall health or function of the enrollee;
2) has a high risk of
hospitalization or other adverse health outcomes; and
3) requires intensive care
coordination.”
As far as what counts as a “chronic
condition”, CMS points to the Medicare Managed Care Manual (section 20.1.2 starting
on page 5). It’s a broad list spanning metabolic conditions, cancers, rare
diseases, behavioral and mental illnesses, substance abuse and more.
So, how big of a market opportunity
is this? That is, as yet, unclear — for a few reasons.
First, it’s uncertain how many
plans will actually offer these expanded benefits. All signs point to strong
interest from the MA market, but the specific numbers vary drastically based on the types of benefits in
question. Secondly, given the substantive policy changes described above, any
trend from 2018 to 2019 will have little bearing on the number of plans
expanding their offerings between 2019 and 2020.
While the number of people and
health plans impacted by this will become clear with the passage of time, there
are some deeper-rooted challenges here that might not.
Deeper Challenges: Money &
Member Engagement
While MA represents a buzzy market
to PE and VC, one thing is important to understand: This is not “new money,”
it’s a redistribution of existing dollars. CMS is not offering additional
funding for new supplemental benefits, but rather providing plans with more
flexibility to match resources to needs.
In some ways this new approach
resembles a simplified “pay for success” scheme, wherein CMS is allowing MA
plans to front the cost of social intervention, prove a positive impact on
health, and then promising them a reimbursement. The economics might work out
here, but the math is still unclear on how which services are covered, how much
they cost, what rate they’re billed, how rigorous CMS intends to be in adjudicating
claims, and so on.
For innovators, the Letter states
that MA plans must incur “a non-zero direct medical cost” for all supplemental
benefits, meaning that in order to be reimbursed for providing a ride or a
meal, a plan must invest those dollars into a specific preventative,
rehabilitative, or otherwise “reasonable” health impact.
This small clause carries serious
potential implications for innovators. If new SSBCIs can only be counted as
non-administrative costs, will plans be reimbursed for investing in new
technology, or will that count as an administrative expense? The Call Letter
hints that CMS’s expectation is that plans make investments in the enabling
technology systems on their own:
“MA plans to develop objective
criteria (e.g., health risk assessments) and maintain detailed documentation
for determining when one chronically ill enrollee is eligible for a particular
item or service and another is not. Note that maintaining detailed internal
documentation is necessary to address potential beneficiary appeals,
complaints, and/or general oversight activities performed by CMS.”
Moreover, the program is entirely
voluntary. All of this simply adds up to the likelihood that despite the
additional spending leeway from CMS, there are no dedicated budgets and
guidelines for 3rd party solutions ala the gold rush days of the HITECH Act.
SDOH Innovators are likely to face a competitive sales process requiring a lot
of customer education, demos, and brand differentiation.
In some ways the MA market
opportunity for SDOH innovation may look more like the world of Medicaid MCOs:
reimbursement conditions vary from state to state and county to county; those
who can do well in one will likely enjoy success in the other.
One of the biggest logistical
wrinkles here might be member engagement. Take for instance, CMS’s requirement
that plans cannot “induce enrollment” by promoting benefits — this may
undermine plans’ ability to drive awareness of the new benefits among seniors
or duals, which could undermine engagement and ultimately utilization. If a
consumer needs a ride, shouldn’t they be able to pick a health plan
accordingly?
As a government program, CMS
mandates all these new benefits are subject to ongoing coverage decisions,
denials, appeals, etc. None of this sounds consumer friendly or easy to use,
and in the first few years of MA plans figuring this out, you can bet it’s not
going to go smoothly all of the time.
A related tangled web is the role
of community partners. CMS allows for community based organizations (CBOs) to
have a seat at the table to do things like help determine eligibility and
deliver support, but it won’t reimburse plans for services rendered by CBOs.
Not only is this shortsighted given how much work and how little money these
organizations receive, but it adds incredible confusion to the member
experience as far as who is responsible for arranging, delivering, measuring, making
decisions, and so on.
2020 & Beyond: Legislation →
Law + Innovate → ROI
As part of this rule, Congress is
authorizing a five year study by the General Accountability Office (GAO) to
analyze frequency of utilization, impact on quality of care, clinical outcomes,
and the impact on plans bidding rates for Part C. The report will go on to
inform subsequent decisions on funding SDOH supports, ultimately influencing
their expansion into Medicare or other insurance programs.
However, given that the US still
lacks a definitive sense of what constitutes “ROI” when it comes to social determinants — this
report could either become a landmark study, a political football, a red
herring or some combination of the above. The closest thing to a crystal ball
on this front may be data from the Center for Medicare and Medicaid Innovation
(CMMI), which just announced an expansion of its Value-Based Insurance Design
(VBID) Model, that also incorporates supplemental benefits based on chronic
conditions, or based only on socioeconomic status.
According to the Call Letter, CMS
is looking for input from stakeholders by March 1st in two areas:
1. “ CMS solicits comment on
whether plans should have flexibility to determine what is a chronic condition
that meets the statutory standard (“is life threatening or significantly limits
the overall health or function of the enrollee”) and if CMS should consider
alternative approaches to determining what meets this criterion.”
2. “CMS is soliciting comments on
the limits of these supplemental benefits discussed here and whether we should
permit consideration of other factors, like financial need, in determining
permissible supplemental benefits for chronically ill enrollees.”
Beyond these areas, there are
several other items that we’d like to see more clarification on, including some
of the key language (“reasonable expectation”) as well as how plans should
think about investing in new technology and business partnerships in light of
meeting the new SSBCI criteria.
Zooming out, CMS states the
“intended purpose of the new category of supplemental benefits is to enable MA
plans to better tailor benefit offerings for the chronically ill population,
address gaps in care, and improve specific health outcomes.” To that end, we’ll
be keeping an eye on this issue as it develops over the course of the year.
No comments:
Post a Comment