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.”
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?’
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.
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.
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.”