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CHRONIC Care Act Prompts Some Medicare Advantage Plans to Incorporate Social Services

In Focus: CHRONIC Care Act Prompts Some Medicare Advantage Plans to Incorporate Social Services

Members of some Anthem-affiliated Medicare Advantage plans may receive up $500 a year to cover expenses for their service animals.

Members of some Anthem-affiliated Medicare Advantage plans may receive up $500 a year to cover expenses for their service animals.

Passed with great fanfare in 2018, the CHRONIC Care Act paved the way for Medicare Advantage plans to begin covering services like adult day care, support for family caregivers, pest control, or other benefits that help members maintain or improve their health. In this issue of Transforming Care, we look at how health plans are responding to the law by changing their benefit offerings and partnering with community-based organizations to promote more holistic, patient-focused approaches to health and wellness. 

You know times are changing when a health plan starts paying for dog food, as Anthem and its affiliated health plans will do in some markets this year. It’s not a marketing gimmick, but a recognition that people who rely on service dogs may need help in supporting them — and that these dogs can play a key role in members’ overall health.

The change is one of many Anthem is making to its Medicare Advantage plans in response to the CHRONIC (Creating High-Quality Results and Outcomes Necessary to Improve Chronic) Care Act, which became law in 2018. The act marks a significant shift in Medicare policy, one that recognizes that many things apart from medical services contribute to health, including whether people can afford basic necessities.

Under the law, which kicks in fully this year, Medicare Advantage plans can opt to pay for benefits like healthy meal delivery (e.g., low-salt dinners for those with heart failure), transportation to the pharmacy or grocery store, home modifications to accommodate walkers and wheelchairs, and other services that may promote health but are not strictly medical in nature.

While health plans were previously allowed to offer supplemental benefits to prevent, cure, or diminish a disease, like a diabetes management class, now they can offer services designed to improve functioning, ameliorate symptoms, and otherwise reduce use of emergency departments or hospitals. Before, health plans were allowed to deliver meals to members after they’d been hospitalized; now, they can provide meals at any time if they think it could help keep people out of the hospital.

In addition, the law waives the uniformity requirement under which plans must offer the same benefits to everyone in a region. Starting this year, plans may offer additional benefits to people with serious chronic conditions (see definition below).

Bringing New Benefits to Medicare Advantage Beneficiaries

Medicare Advantage plans have long provided coverage for dental, vision, and hearing services that are not covered by traditional Medicare. Some plans also offer gym memberships, disease management classes, and other benefits intended to prevent or ameliorate disease.

The CHRONIC Care Act gives plans new flexibility to offer nonmedical benefits, but it does not mandate plans do so or prescribe particular benefits. The new benefits must have a “reasonable expectation” of improving or maintaining beneficiaries’ health or functioning by targeting their living conditions, nutrition, or other social determinants of health.

Starting in 2019: Plans were able to offer a broader range of benefits to any member, including: adult day care, in-home personal care attendants, support for family caregivers, home safety and assistive devices (e.g., grab bars or wheelchair ramps), and non-opioid pain management (e.g., acupuncture or massage).

Starting in 2020: Plans may offer special supplemental benefits for the chronically ill. These are limited to members who: 1) have at least one complex chronic condition that is life threatening or significantly limits overall health or function, 2) are at high risk of hospitalization or other adverse health outcomes, and 3) require intensive care coordination. These benefits could include services such as nonmedical transportation, home-delivered meals, help with daily activities, or minor home repairs.

Source: Jane Sung and Claire Noel-Miller, AARP Public Policy Institute, Supplemental Benefits in Medicare Advantage: Recent Public Policy Changes and What They Mean for Consumers, July 2019.

Medicare has traditionally steered clear of funding nonmedical services and instead leaned on state Medicaid programs to cover benefits like home aides, transportation, or adaptive technology for frail elders and beneficiaries with disabilities. Known as long-term services and supports, these benefits reach only the poorest beneficiaries and are quite limited in some states. Other supports for seniors, like home-delivered meals, are funded by the Older Americans Act and private philanthropy, and there’s wide variation in what’s available across the country.

In this issue of Transforming Care, we look at how health plans and community-based organizations have responded to the CHRONIC Care Act and consider its potential benefits and challenges.

How Health Plans Are Responding

Many health plans were taken aback by how broadly Centers for Medicare and Medicaid Services (CMS) officials interpreted the term “non-primarily health related” in their April 2019 call letter, which outlines payment and coverage policies for companies bidding to sell Medicare Advantage plans the following year.

In addition to supporting more flexible use of food and transportation benefits, as was anticipated, CMS officials said plans could offer members with chronic conditions benefits that are far afield from health care, like pest control, carpet cleaning, and air conditioning units. CMS officials also placed no limit on their duration.

Given the uncharted territory — and the fact that plans are not receiving additional money to pay for new benefits — many health plans leaders have proceeded cautiously, often by piloting a handful of benefits related to food delivery or transportation, for which there are precedents and evidence of effectiveness, or offering new benefits in a limited number of communities.

We know that a service dog comes with a financial burden and this allowance gives members more buying power to improve the health of their service dog and more resources to drive better health for themselves.

Martin Esquivel Vice president for Medicare product management, Anthem

Anthem: Offering a Menu of Services

Anthem, a national insurer, is an exception. In 2020, Anthem and its affiliates are offering Medicare Advantage members in 14 markets the opportunity to choose at least one new benefit from a menu of 10 options (with some variations across markets).1 The benefits take aim at a wide range of social problems including food insecurity and social isolation; others are designed to help elderly members maintain their independence. They include:

  • For those with certain clinical criteria, access to eight sessions per year with a dietitian as well as monthly delivery of pantry staples.
  • Quarterly preventive treatments to regulate or eliminate household pests that may impact a chronic condition.
  • A fitness tracker device as well as membership in programs to promote physical and mental fitness.
  • Up to $500 annual allowance to help pay for items for a member’s service dog.
  • Up to 16 delivered meals four times a year (64 total) for members who are hospitalized, have a body mass index over 25 or less than 18, or have a hemoglobin A1c level over 9.0.
  • Up to 60 one-way trips per year to health-related appointments or to obtain a service covered by the health plan.
  • Up to 124 hours of an in-home personal care aide for assistance with activities of daily living such as dressing, grooming, and bathing.
  • Up to a $500 allowance for home safety devices, such as grab bars.
  • Up to one visit per week for adult day center services.
  • Up to 24 acupuncture and/or therapeutic massage visits per year.

The benefits are not limited to those with low incomes. “We know people who are fine financially but have issues with social isolation or have difficulty driving a car to the doctor and they don’t have the social network to get them there,” says Martin Esquivel, vice president for Anthem’s Medicare product management.

Out of the gate, transportation and acupuncture were the most popular, but members have increasingly chosen the personal assistance benefit as they learn more about it. Esquivel says Anthem will continue to refine its offerings as the company gains insights about members’ preferences. One open question is whether to use a menu at all. Doing so enables the health plan to offer more robust services than offering “skinnier versions” of all, he says. But in parts of California and Arizona, Anthem-affiliated health plans give members access to all these supplemental benefits instead of asking them to choose from a menu of options, a pilot that may become standard practice in highly competitive markets.  

UCare: Starting Small

UCare, a nonprofit health plan with about 105,000 Medicare Advantage members in Minnesota and western Wisconsin, brought together staff with expertise in disease management, pharmacy, finance, product development, and other areas to brainstorm ways to respond to the CHRONIC Care Act. After reviewing market research about what extra benefits are most appealing to members, they decided to offer an acupuncture benefit to members who may need help managing pain related to such conditions as cancer, multiple sclerosis, and fibromyalgia. “We want to make sure people have access to services that treat pain with more limited involvement of opioids,” says Liz Conway, product manager director. “Our goal is as much to avoid future opiate dependency as to counter current use.”

Starting this year, UCare is offering acupuncture benefits with no copayments or limitations in its Twin Cities market, where it has both a critical mass of members who’ve expressed interest in the benefit and a network of acupuncturists. Because only some UCare members are eligible, the health plan does not plan to advertise the benefit but instead will engage directly with members who have certain diagnoses and ask clinicians to help make them aware of it.

Humana’s “Bold Goal” to Reduce Food Insecurity, Social Isolation

Before the passage of CHRONIC, some health plans were using charitable dollars, community partnerships, and other efforts to improve population health by confronting social challenges. In 2015, Humana launched the Bold Goal initiative, an effort to improve members’ health 20 percent by 2020 and beyond by identifying the social determinants of poor health and partnering with community organizations to address them. The insurer is working in 14 markets, where thus far some 1 million members have been screened. About 15 percent of Medicare Advantage plan members reported being food insecure and about 37 percent report being socially isolated — both factors that put people at increased risk of getting sick and accruing higher medical spending. “When you have someone with a chronic condition and put social needs on top there’s an exponential increase in cost,” says Andrew Renda, M.D., Humana’s associate vice president for population health. “That’s the perfect storm we’re trying to avoid.”

In Tampa, for example, Humana invites seniors that its data flag as being at risk for loneliness to join a “grandkids-on-demand” program, in which college students offer companionship, help with chores, technology lessons, and other support. And in Knoxville, Tenn., and Kansas City, Mo. and Kan., it partners with Walgreens to screen thousands of people for food insecurity (regardless of their insurance) and refer those who screen positive to local food resources and federal nutrition benefits. They’ve also created toolkits to enlist clinicians’ help in identifying and addressing food insecurity. This year, Humana will introduce grocery benefits for 50,000 members in its Medicare Advantage Special Needs Plans (for people eligible for both Medicare and Medicaid).

Since 2015, Humana has tracked a 2.7 percent decrease in the number of unhealthy days in a month among members in Bold Goal communities, compared with an increase of 0.6 percent among members in other communities. (Developed by the Centers for Disease Control and Prevention, healthy days measures ask people about their physical and mental health over the prior 30 days.) In San Antonio, where the mayor has prioritized health and several sectors have gotten involved, there has been a 9.8 percent decrease in the number of unhealthy days. These changes translate into meaningful returns: for every additional unhealthy day, there are 10 more hospital admissions per 1,000 members, according to Humana.

The Role of Community-Based Organizations

Health plans that want to offer new health-related benefits must decide whether to contract with community-based organizations (CBOs) to provide them or develop capacity to do it themselves.

Many CBOs have long experience in delivering social services to the elderly, but health plans may find it hard to contract with various CBOs in different parts of the country or ones that specialize in particular services. Along with the logistical challenges, partnerships between health plans and CBOs must bridge different cultures, says Michelle Herman Soper, vice president for integrated care at the Center for Health Care Strategies, which has worked with managed care plans that have engaged CBOs in efforts to enhance integrated care models for people enrolled in Medicaid and Medicare. “You have to be willing to make investments in CBOs’ data and reporting capacity and get people on board to think about shared outcomes and shared accountability,” she says.

Given these challenges, some large, national nonprofit organizations are positioning themselves as partners to Medicare Advantage plans in providing social services.

Managed care plans are concerned about building networks of social service providers. They say, ‘We have just figured out how to contract with physicians. Now we have to contract with the Orkin man?’

Alesia Frerichs Vice president of member engagement, Lutheran Services in America

Lutheran Services in America

Member organizations of Lutheran Services in America, a national network of 300 health and human services providers, offer services to seniors including housing and residential care, caregiver support, transportation, and nutrition. The network created LSA Senior Connect to offer a service coordination platform. “We know there is fragmentation in the nonprofit human services sector, with many organizations providing a variety of services in a variety of ways with a variety of outcomes,” says Charlotte Haberaecker, Lutheran’s president and CEO. “LSA Senior Connect is a national solution that can be deployed on a grassroots level.”

The approach is being piloted among 465 residents of a low-income senior housing facility in Toledo, Ohio. For the pilot, staff social workers were trained to conduct a comprehensive screening of residents’ mobility and functional skills, home safety and security, nutrition, transportation, and social engagement. In addition to asking questions, social workers observe residents’ movements and home environments to see how well they get around, how often they leave their apartments, and whether they have sufficient food or other necessities, for example. “Our goal is to identify folks before they become high need,” says Haberaecker.

In Focus: CHRONIC Care Act Prompts Some Medicare Advantage Plans to Incorporate Social Services

Minnesotan senior Carol Crust (L) meets with Renee Ransom, a health and wellness–related volunteer with Lutheran Social Service of Minnesota.

The pilot uncovered 385 needs, including for socialization, healthy food, reliable transportation to medical appointments, in-home supports, and physical therapy. Staff have been able to address most by connecting seniors to benefits or community resources, and they hope to demonstrate the impact of these services by tracking health care service use and costs.

Lutheran Services in America is also partnering with UnitedHealthcare in a data-sharing pilot that will enable the insurer to examine how members’ social needs relate to their health service use and outcomes.

Meals on Wheels

Meals on Wheels America is also leveraging its strong relationships with elderly Americans to identify and ameliorate social problems. In recent years, the national organization, which supports 5,000 local Meals on Wheels programs, has had contracts to deliver meals to members of Humana, Blue Cross of Idaho, and Aetna.

Typically, volunteer drivers deliver meals to the same seniors each week, so they can get to know them and assess how they’re faring; some meals are tailored to adjust for seniors’ medical conditions. The programs also do an extensive intake of new clients and often find resources for those in need of companionship or other supports. Some Meals on Wheels sites also deploy Johns Hopkins’ CAPABLE program, in which a registered nurse, occupational therapist, and handy worker support elders to increase their independence and reduce safety hazards. A trial of CAPABLE among low-income elders with functional limitations found that it produced $22,000 in medical cost savings for a $3,000 investment.

Evidence of effectiveness led Meals on Wheels and a Medicare Advantage plan to consider a “pay-for-success” pilot, whereby the plan would advance funds to pay for Meals on Wheels services with the agreement that both parties would share in any savings from reduced medical expenses. Ultimately, this proved complicated because of the difficulty of attributing changes to certain services. “It’s not for the light-hearted to pull one of these contracts off,” says Lucy Theilheimer, chief strategy and impact officer for Meals on Wheels America. The plan eventually opted to pay for Meals on Wheels directly.

Challenges Ahead

While there is widespread agreement on the importance of addressing social risk factors, experts say health plans’ forays into providing social services may go slowly given the challenges in identifying needs, building referral systems (particularly in rural communities and other lower-resource areas), monitoring quality, and establishing a clear return on investment.

Foremost among plan leaders’ concerns is maintaining members’ satisfaction ratings, as these affect their star ratings and help determine whether they earn rebate dollars that can be used to fund supplemental services. “They want to make sure that they have community partners that can deliver,” says Kali Thomas, Ph.D., an associate professor of health services, policy, and practice at Brown University, who surveyed leaders of 17 Medicare Advantage plans about their views on using CHRONIC to address members’ social needs.

To pay for supplemental benefits, insurers can use administrative or rebate dollars; the latter vary across plans and regions and average around $107 per member per month. Given the lack of additional funds, health plans must carefully choose which members may benefit from additional supports — a process that may require more refined screening for social risk. Humana, UnitedHealthcare, the American Medical Association, and others are advocating for CMS to include additional diagnostic codes, so that providers can flag patients’ particular social challenges with greater precision. Ideally, health plans will be able to identify members who at are risk for medical problems, but who have not yet needed the hospital or emergency department, says Parie Garg of Oliver Wyman’s health and life sciences practice.

Some advocates worry that Medicare Advantage plans will use risk adjustment to increase payment but may not use the extra dollars to target areas of greatest need. There is also a risk they may downplay their supplemental offerings to avoid attracting sicker patients. Experts also say CMS might need to compel greater disclosure of plan benefits and their use, so that researchers can help answer the question of what works and why. And health plans need to do more to ask members themselves about what kinds of support they need. Such investigations may produce the evidence needed to craft similar benefits for fee-for-service Medicare beneficiaries.

“Right now, we only know in very general terms which benefits will be offered in 2020. It’s still very new, and although we’re excited about the potential, we don’t know anything about outcomes: Will consumer satisfaction increase? Will there be an impact on cost and utilization? How much will the benefits vary from year to year?” says Mary Kaschak, executive director of the Long-Term Care Quality Alliance. “These are the $64,000 questions.”

Editorial Advisory Board, January 2020

Special thanks to Editorial Advisory Board member Eric Coleman for his help with this issue.

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., professor of medicine, University of Colorado

Michael Chernew, Ph.D., professor of health policy, Harvard Medical School

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, RAND Corp.

Allison Hamblin, M.S.P.H., vice president for strategic planning, Center for Health Care Strategies

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Lauren Murray, director of consumer engagement and community outreach, National Partnership for Women & Families

Kathleen Nolan, M.P.H., regional vice president, Health Management Associates

J. Nwando Olayiwola, M.D., M.P.H., associate professor of family and community medicine, University of California, San Francisco, School of Medicine

James Pelegano, M.D., M.S., assistant professor of healthcare quality and safety, Thomas Jefferson University

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, Dr.P.H., executive director, Center for Care Innovations

Mark A. Zezza, Ph.D., director of policy and research, New York State Health Foundation

Publications of Note: October–December 2019

Opportunities to Reduce Waste in U.S. Health Care System Abound

Researchers estimated the cost of waste in the U.S. health care system at between $760 billion to $935 billion per year, accounting for 25 percent of health care spending. To develop the estimate, they focused on six domains: failure of care delivery (accounting for $102.4 to $165.7 billion in waste), failure of care coordination ($27.2 billion to $78.2 billion), overtreatment or low-value care ($75.7 billion to $101.2 billion), pricing failure ($230.7 billion to $240.5 billion), fraud and abuse ($58.5 billion to $83.9 billion), and administrative complexity ($265.6 billion). The study notes the potential savings from interventions that reduce waste, excluding savings from reducing administrative complexity, range from $191 billion to $282 billion. The findings are extrapolated from data from peer-reviewed publications, government-based reports, and reports from the gray literature. William H. Shrank, Teresa L. Rogstad, and Natasha Parekh, “Waste in the U.S. Health Care System: Estimated Costs and Potential for Savings,” Journal of the American Medical Association 322, no. 15 (October 2019):1501–9.

Participation in Food Stamp Program Reduces Mortality Rate

A study examining the relationship between participation in the Supplemental Nutrition Assistance Program and premature mortality among adults found participation in the largest food assistance program in the U.S. led to a population-wide reduction of 1-to-2 percentage points in mortality from all causes and a reduction in specific causes of death among people ages 40 to 64. The authors say more research is needed to understand the impact of the program on health outcomes for conditions influenced by nutrition (e.g., hypertension, hypoglycemia, and obesity). Colleen M. Heflin, Samuel J. Ingram, and James P. Ziliak, “The Effect of the Supplemental Nutrition Assistance Program on Mortality,” Health Affairs 38, no. 11 (November 2019):1807–15.

Strategies for Tailoring Quality Improvement Efforts for High-Need Populations

The authors of this commentary in the Journal of the American Medical Association suggest that recent national initiatives to improve the quality of U.S. health care have had limited impact because they are too diffuse and fail to target the most important issues for specific groups of patients. They recommend ways of customizing quality improvement programs for three subpopulations: patients with advanced illness near the end of life, frail older adults, and nonelderly disabled patients with serious mental illness. For patients nearing the end of life, they recommend the Centers for Medicare and Medicaid Services (CMS) track the number of healthy days at home to ensure patients’ general preferences to remain at home are honored. For frail older adults, they suggest CMS concentrate on reducing potentially avoidable hospitalizations and monitor not just hospitalizations but emergency department (ED) visits and observation stays related to ambulatory care–sensitive conditions. For nonelderly disabled patients with serious mental illnesses, they suggest supporting programs that integrate primary care and mental health services and tracking excess spending related to acute care services that result from inadequate management of mental illnesses. Jose F. Figueroa, Kathryn E. Horneffer, and Ashish K. Jha, “Disappointment in the Value-Based Era: Time for a Fresh Approach,” Journal of the American Medical Association 322, no. 17 (November 2019):1649–50.

Commercial Accountable Care Organization Reduces Outpatient But Not Inpatient Spending

A study evaluating the long-term impact of a commercial accountable care organization (ACO) on health care spending, utilization, and quality outcomes among continuously enrolled members found the ACO improved outpatient process measures modestly and slowed outpatient spending growth by the fourth year of operation, but had a negligible impact on inpatient cost, use, and quality measures. The two ACO cohorts studied had increased inpatient and outpatient spending in the first two years of ACO operation. The reductions in outpatient spending in the latter two years came from reduced primary care visits and lower spending on specialists, testing, and imaging. The researchers found no differential changes in inpatient spending, utilization, and quality measures for most of the five years, and favorable results for several quality measures in preventive and diabetes care domains in at least one of the five years. Hui Zhang et al., “Five-Year Impact of a Commercial Accountable Care Organization on Health Care Spending, Utilization, and Quality of Care,” Medical Care 57, no. 11 (November 2019):845–54.

Chronic and Acute Health Care Needs Higher for Children in Food Insecure Households

Researchers found for children, household food insecurity was related to significantly worse general health, some acute and chronic health problems, and worse health care access, including forgone care and heightened emergency department (ED) use. Compared with rates in households that were not food insecure, children in food insecure households had rates of lifetime asthma diagnosis and depressive symptoms that were 19.1 percent and 27.9 percent higher, respectively; rates of forgone medical care that were 179.8 percent higher; and rates of ED use that were 25.9 percent higher. No significant differences were observed for most communicable diseases, such as ear infections or chicken pox, or conditions that may develop more gradually, including anemia and diabetes. Margaret M. C. Thomas, Daniel P. Miller, and Taryn W. Morrissey, “Food Insecurity and Child Health,” Pediatrics 144, no. 4 (October 2019):e20190397.

Lack of Access to Specialists in Rural Communities Linked to Preventable Hospitalizations and Deaths

Researchers found lack of access to specialists was associated with higher rates of mortality and preventable hospitalizations for rural Medicare beneficiaries living with complex chronic conditions. They found that rural residence was associated with a 40 percent higher preventable hospitalization rate and a 23 percent higher mortality rate while having one or more specialist visits during the previous year was associated with a 15.9 percent lower preventable hospitalization rate and a 16.6 percent lower mortality rate. The researchers found having access to specialists accounted for 55 percent and 40 percent of the rural–urban difference in preventable hospitalizations and mortality, respectively. Kenton J. Johnston, Hefei Wen, and Karen E. Joynt Maddox, “Lack of Access to Specialists Associated with Mortality and Preventable Hospitalizations of Rural Medicare Beneficiaries,” Health Affairs 38, no. 12 (Dec. 2019):1993–2002.

Rural Counties with Black or Indigenous Populations Suffer Highest Rates of Premature Death

Researchers using county-level data to measure and compare premature death rates in rural counties by each county’s majority racial/ethnic group found that premature death rates were significantly higher in rural communities with a majority of non-Hispanic black or American Indian/Alaska Native residents than in rural counties with a majority of non-Hispanic white residents. They recommend that policymakers seeking to improve rural health focus on racially diverse communities and address economic vitality to mitigate health inequities and the harmful health effects of neglecting social determinants of health. Carrie E. Henning-Smith et al., “Rural Counties with Majority Black or Indigenous Populations Suffer the Highest Rates of Premature Death in the U.S., Health Affairs 38, no. 12 (December 2019): 2019–26.

Risk of Severe Maternal Morbidity and Mortality Higher in Rural Communities

Researchers who analyzed data on severe maternal morbidity and mortality during childbirth hospitalizations among rural and urban residents found severe maternal morbidity and mortality increased among both rural and urban residents in the study period, from 109 per 10,000 childbirth hospitalizations in 2007 to 152 per 10,000 in 2015. After controlling for sociodemographic factors and clinical conditions, they found that rural residents had a 9 percent greater probability of severe maternal morbidity and mortality, compared with urban residents. They say attention to both clinical factors (workforce shortages, low patient volume, and the opioid epidemic) and social determinants of health (transportation, housing, poverty, food security, racism, violence, and trauma) are necessary to reduce maternal morbidity and mortality in rural areas. Katy Backes Kozhimannil et al., “Rural-Urban Differences in Severe Maternal Morbidity and Mortality in the U.S., 2007-15,” Health Affairs 38, no. 12 (December 2019):2077–85.

Social Needs Navigation Reduces Utilization Among Some Groups

Researchers found a telephonic social needs screening and navigation program led to significant decreases in utilization among low–socioeconomic status patients but had modest effects on the population overall. The program focused on patients who were predicted to be high utilizers of outpatient, ED, and inpatient services (the highest 1% of total utilization in a large integrated health system). They found most patients screened (53%) reported social needs but only a minority (10%) with a need were able to connect with resources to address those needs. They found total utilization visits decreased 2.2 percent in the intervention group but decreases in total utilization were greater for certain subgroups: those in low-income areas (-7%), in low-education areas (-11.5%), and those covered by Medicaid (-12.1%). Adam Schickedanz et al., “Impact of Social Needs Navigation on Utilization Among High Utilizers in a Large Integrated Health System: A Quasi-Experimental Study,” Journal of General Internal Medicine 34, no. 11 (November 2019):2382–9.

Ensuring Greater Spending on Primary Care Yields Savings

In a commentary in the Journal of the American Medical Association, the authors explore the reasons that increased spending on primary care may not yield downstream savings and recommend that policymakers consider complementary delivery system interventions to ensure savings, such as regulation to address rising prices or value-based insurance design to lower cost-sharing for preventive care. They also suggest policymakers consider enhancing the substance of primary care by equipping practices to address the social determinants of health, reducing the administrative burden on practices to create more time for patient care, and changing malpractice laws to lessen defensive medicine. Zirui Song and Suhas Gondi, “Will Increasing Primary Care Spending Alone Save Money,” Journal of the American Medical Association 322, no. 14 (October 2019):1349–50.

Assessing Medicaid Expansion’s Impact on Health

The authors of this commentary in the Journal of the American Medical Association summarize the evidence to date on whether Medicaid expansion has resulted in improved health for low-income residents. They describe studies that have documented improvements in self-reported health; some, but not all, acute and chronic disease outcomes; and mortality reductions. They say the literature is less definitive on whether Medicaid expansion increases access to care and promotes financial well-being. Going forward, they recommend researchers focus on whether low-income populations are healthier after gaining Medicaid coverage and whether Medicaid expansion is the most effective or efficient means of improving health or whether alternative investments in private insurance expansion, social services, or direct safety-net funding would be more or less effective ways of doing so. Heidi Allen and Benjamin D. Sommers, “Medicaid Expansion and Health: Assessing the Evidence After 5 Years,” Journal of the American Medical Association 322, no. 13 (October 2019):1253–54.

Medicaid Work Requirement in Arkansas Sowed Confusion, Declines in Enrollment

A survey of low-income adults in Arkansas, which imposed work requirements on Medicaid beneficiaries in 2018, found the requirement was associated with significant losses of health insurance coverage in the initial six months of the policy but no significant change in employment. The authors say lack of awareness and confusion about the reporting requirements may explain why thousands lost coverage even though 95 percent of the target population appeared to meet the requirements or qualify for an exemption. They estimate the state reduced Medicaid enrollment by 12 percentage points. Benjamin D. Sommers et al., “Medicaid Work Requirements — Results from the First Year in Arkansas,” New England Journal of Medicine 381, no. 11 (September 2019):1073–82.


1 In Ohio, one health plan is offering the same 10 choices but some benefits may be different. For Amerigroup New Jersey, the benefits package will either give members access to four services (i.e., alternative medicine, delivered meals, assistive devices, and personal home helper) or they’ll be able to choose one of 10 options, depending on the plan.

Publication Details



Martha Hostetter and Sarah Klein, “In Focus: CHRONIC Care Act Prompts Some Medicare Advantage Plans to Incorporate Social Services,” Transforming Care (newsletter), Jan. 9, 2019.