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Opinion

A Game Changer in Medicare Coverage

It is not often that those of us in the world of health policy get to celebrate important moments that have the potential to transform health care, but this year’s Advance Notice for Medicare Advantage announced by the Centers for Medicare and Medicaid Services offered us such a moment.

As required by an act of Congress, CMS was required to expand the definition of allowable use of supplemental benefits in Medicare Advantage to better meet the needs of those with chronic conditions. The proposed guidance announced recently did that by allowing plans to offer meals and nutrition, as well as transportation targeted specifically to beneficiaries with chronic conditions. This follows guidance announced last year that added in-home care and home modifications to allowable supplemental benefits.

This is a game-changer for Medicare beneficiaries who have chosen Medicare Advantage, and it could offer lessons that could impact traditional Medicare and all of health care. Here’s why.

As more and more Medicare beneficiaries have complex clinical conditions, and as increasing numbers chose Medicare Advantage, more plans and providers have used the flexibility of a full-risk, capitated system of payment to not only provide good care when individuals come to the office or hospital for treatments and procedures, but to find ways to better enable patients to improve their health.

To do so, they are engaging patients, particularly those who are managing chronic conditions, with ongoing primary care and care coordination as part of an integrated care system. Still, clinical care alone is too often not enough.

Meeting social, emotional and economic needs is essential to enabling patients to improve their health. Plans and providers that care for Medicare Advantage enrollees have learned through experience that addressing these social determinants of health is imperative to improve an enrollee’s health status and health outcomes.

Medicare Advantage has been stretching to meet these nonmedical needs and has the capacity to do so because of the flexibility that allows plans to offer supplemental benefits. Partnering with community organizations such as Meals on Wheels, a network of local volunteer-based meal delivery programs across the country, to deliver healthy meals has shown strong evidence of reduced readmissions.

And recent findings from Humana, a national Medicare Advantage organization, demonstrated that offering transportation benefits in its Medicare Advantage plans improved patient utilization of recommended preventive services such as breast cancer screenings and eye exams for diabetics. Plans, providers and enrollees value these supportive services, finding that they increase engagement between patients and care providers and enable patients to get to the care they need.  

The proposed guidance opens the door to such expanded services allowed through supplemental benefits such as transportation, meals and nutrition, specifically for those who are chronically ill. CMS defines this targeted population as an individual who has one or more co-morbid and medically complex chronic conditions that is life-threatening or significantly limits the overall health or function of the enrollee, has a high risk of hospitalization or other adverse health outcomes, and requires intensive care coordination. These are complex patients with high needs for whom these services may make the difference in enabling them to live healthier lives.

Addressing the clinical, as well as the non-medical, needs of these high-need beneficiaries offers the opportunity for improved care and better cost, while resulting in better health for these patients. CMS should finalize this new rule in the Final Rate Notice. Policymakers looking for new ways to meet the needs and expectations in health care for all Americans should look to the models being created by Medicare Advantage plans, providers and community partners in caring for some of the sickest and most vulnerable individuals.

 

Allyson Y. Schwartz is president and chief executive officer of the Better Medicare Alliance and is a former U.S. representative from Pennsylvania.

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