Three in four Americans over 65 live with multiple chronic conditions, such as diabetes, heart disease and asthma, and the cost of providing their care is rapidly increasing.
Beginning in January, Medicare Advantage, or MA, Medicare's managed care plans, will offer some relief by providing health-related supplemental benefits to beneficiaries with chronic conditions. Some plans will offer new benefits such as smoking cessation programs, in-home personal assistance, caregiver support and adult daycare. But that's not enough.
Supporters of the chronic care provisions in the Bipartisan Budget Act of 2018 were disappointed that the 2019 guidance on benefits did not sufficiently assist patients with complex needs. However, the new law gives the Centers for Medicare and Medicaid Services the authority to change its guidance for 2020 and allow MA plans to offer important nonmedical services. BPC has supported removing health-related limitations on benefits to permit broader coverage of services such as home-delivered meals, nonemergency medical transportation, minor home modifications and other services designed to reduce hospitalization rates for Medicare's sickest enrollees.
Medicare beneficiaries with four or more chronic conditions account for 90 percent of Medicare hospital readmissions and 74 percent of overall Medicare spending. Research shows that providing social services not traditionally covered by Medicare can reduce unnecessary hospitalizations and emergency visits for some people living with multiple chronic conditions.
Under the new budget law, these benefits must have a reasonable expectation of improving health or maintaining overall function for the most expensive Medicare patients.
Health care providers who work with chronically ill patients and their families are more successful in keeping patients out of hospitals and emergency rooms when they provide care based on what is needed, rather than what is covered under Medicare.
The ability to offer services to those with complex needs is critical to improving health care quality and lowering costs. Practices that provided benefits to all enrollees or offered benefits to those with only one chronic condition — rather than targeting individuals with multiple chronic conditions — were not fiscally sustainable in the long run. Only those that provided additional benefits to patients with multiple chronic conditions were successful.
Consumer advocates have been understandably concerned about these new targeted supplemental benefits. In the early days of Medicare managed care, plans used benefits such as golf club memberships to attract healthier Medicare beneficiaries.
Advocates also worry about confusing Medicare beneficiaries who enroll in a plan based on a benefit, only to discover later that they don't meet the conditions set by plans to receive the services. These are valid concerns and CMS should make sure that materials provided to beneficiaries are clear and understandable. Addressing these issues through oversight and data collection could not only help seniors enrolled in MA plans, but it could ultimately be used to support offering effective benefits for Medicare fee-for-service beneficiaries, too.
Most MA plans will not offer targeted supplemental benefits in 2019 as they wait for more data and guidance from CMS, specifically on what type of benefits would be approved. Some have likened it to playing a game of "Battleship," in which they seek approval of a service, and wait for CMS to let them know whether their proposed benefit was a "hit" or a "miss."
The number of older Americans is expected to double by 2050, putting a significant strain on the nation's health care system — and on families, too. We encourage the secretary of Health and Human Services and CMS to issue additional guidance early next year that permits broader coverage of services for those with multiple chronic conditions. We also urge them to issue guidance to address concerns raised by consumer advocates. This would also give plans sufficient notice to make changes for plan year 2020 and help beneficiaries navigate a complicated enrollment process.
Offering plans more flexibility with their benefits by including nonmedical services is a real opportunity to shift toward more patient- and family-centered care. It could help transform the United States from a system of care based on what is covered by Medicare, to care based on what patients and their families need to remain at home, where most patients want to be.