New Medicare Advantage rules hold big potential for pop health

June 14, 2018 / in News / by admin


The push toward valued-based care and population health management has raised visibility around nonmedical conditions that impact health outcomes.

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 America to 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.