By Anne Tumlinson Innovations and Long Term Quality Alliance
New flexibility for Medicare Advantage (MA) plans represents a major turning point in Medicare policy, and an opportunity for health insurers and providers to work together in new and more productive ways.
The prevalence of chronic disease among MA plan members now mirrors that of Medicare beneficiaries in traditional fee-for-service (FFS). About 6 percent of MA enrollees report having congestive heart failure (CHF), 20 percent report chronic obstructive pulmonary disease (COPD), 33 percent report diabetes, and about 8 percent report dementia. These rates closely track rates of self-reported chronic conditions among FFS beneficiaries: CHF (6.9 percent), COPD (19.5 percent), diabetes (30 percent), and dementia or Alzheimer’s disease (7.6 percent).
MA plans increasingly recognize that non-medical services, such as care in the home, transportation, meals, and social supports, are needed to manage the health care costs of chronically ill members. Until recently, however, Medicare prohibited insurers from using health care dollars to meet the non-medical needs of chronically ill enrollees.
Recognizing MA plans’ need for better tools to effectively serve chronically ill members, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018, which included the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act. This new law expands the criteria for what qualifies as a supplemental benefit to meet the needs of chronically ill MA enrollees. It acknowledges that efficient health care delivery for a chronically ill population hinges on the ability of providers and payers to address individual needs, not all of which may be primarily health-related, but which may have a significant impact on health and health care utilization.
Subsequent guidance from the Centers for Medicare & Medicaid Services (CMS) gives MA plans significant flexibility to offer a wide range of benefits for chronically ill beneficiaries, such as wheelchair ramps, meals, and home care, and to target them narrowly to meet individual needs. These new special supplemental benefits for the chronically ill (SSBCI) represent a major turning point in Medicare policy and a departure from two longstanding principles of the program: 1) all beneficiaries must receive the same benefits under uniformly applied eligibility rules; and 2) Medicare pays only for services and benefits that are primarily related to health.
While SSBCI are a relatively small part of the MA program, the significance of this shift highlights a need for new principles to guide implementation of SSBCI. For the SSBCI to be developed and adopted, they must work for many stakeholders: health plans, service providers, the Medicare program, and beneficiaries. In recognition of this, a working group of experts and stakeholders, representing consumers, providers, and health plans, has convened. The group was charged with creating a new set of principles that can inform regulation development and benefit design, and form the basis of a common language for everyone, including CMS, health plans, delivery systems, advocates, and Congress.
The working group identified five guiding principles for new flexibility under SSBCI: one core principle and four principles that balance opportunities and challenges created by the new benefit flexibility.
The guiding principles are aspirational. The benefits offered through SSBCI can be helpful in meeting a short-term need or as part of a larger effort, but they are not a solution by themselves for people with long-term functional assistance needs. The Guiding Principles help to frame SSBCI in a larger context of the resources needed and the role that SSBCI can play in meeting those needs.
Core principle: SSBCI reflect individual need. For the first time, through SSBCI, chronically ill individuals may be covered by benefits that meet their specific needs, in the context of improving or maintaining their health. The balancing principles include:
- SSBCI are clear and understandable: Key stakeholders understand SSBCI, as well as their limitations and the circumstances under which they are available.
- SSBCI are equitable: Chronically ill MA enrollees receive SSBCI in a consistent, equitable, and nondiscriminatory manner that determines and meets individual need based on chronic illness and functional status.
- SSBCI are manageable and sustainable: Medicare program regulations and guidance, such as rate structures and quality measures, support MA plans in offering, managing, and sustaining SSBCI in MA plan benefit packages.
- SSBCI evolve with continuous learning and improvement: The federal Department of Health and Human Services and CMS, in conjunction with MA plans and other stakeholders, evaluate and measure the extent to which SSBCI are contributing toward meeting the needs of chronically ill enrollees and adapt SSBCI accordingly based on these learnings.
The Evolution of Provider-Payer Relationships: A New Role for Hospitals and Health Systems
The new benefits will require an unprecedented degree of collaboration among all stakeholders, and the inclusion of SSBCI in plan benefit packages will encourage new types of relationships between providers and MA plans.
MA plans will need hospitals, health systems, and large physician groups to help them identify and build networks for a wide range of community-based services and non-medical services and supports. These service providers have little to no experience contracting with MA plans. They are not currently organized in coherent and integrated delivery systems. Hospitals and large physician groups can leverage their experience contracting with health plans and their knowledge of their communities to connect MA plans with non-medical services providers and community-based organizations.
Medicaid managed long-term services and supports (MLTSS) organizations have experience working with non-traditional, non-medical providers. MA plans can also look to their MLTSS counterparts for expertise and assistance in building networks of community-based organizations and non-traditional service providers.
New partnerships are already underway. Amedisys — one of the nation’s largest home health and hospice providers, with strong MA plan relationships — partnered with ClearCare Inc., a personal care technology solution, to connect MA plans with networks of home health and home care providers. This is an example of the type of partnership that MA plans will come to increasingly value, as they build capabilities to offer non-medical supports and services and to better manage a growing enrollee population of individuals with chronic conditions and complex care needs.
Editor’s note: Click here to learning more about the guiding principles for SSBCI discussed in this blog post.