By: Howard Gleckman
Congress is taking a small, but important, step towards expanding Medicare to include some long-term supports and services. A bipartisan (yes, bipartisan) measure before the Senate Finance Committee would give some Medicare providers additional flexibility in the way they care for people with chronic conditions, who are among the program’s highest need and highest cost beneficiaries.
The bill, called the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, nibbles around the edges of this important issue. Make no mistake, it would not expand traditional Medicare to provide anything like a long-term care benefit. Far from it. But it would begin to break down what has until now been a largely impenetrable wall between Medicare and those supports and services.
Given the current political environment, Congress would take a major step by even acknowledging that people with chronic conditions may require services that Medicare does not now offer. The sponsors of the bill include Finance Committee Chair Orrin Hatch (R-UT) and top committee Democrat Ron Wyden (D-OR) as well as Johnny Isakson (R-GA) and John Warner (D-VA). The Finance panel held a hearing this on the bill yesterday and plans to vote next week to send the measure to the full Senate.
Expanding Managed Care
CHRONIC would expand the use of telehealth, extend and expand a home-based medical practice experiment called Independence at Home, and improve the Medicare appeals process for people in risk-based insurance plans such as Special Needs Plans (SNPs). But the biggest changes would apply to the care provided by managed care programs.
One would expand the use of those special needs plans, which are explicitly aimed at people with chronic conditions and high medical needs. Some of these programs already provide supports and services as part of their benefit packages but they remain relatively small.
The other would give Medicare Advantage plans important new flexibility to offer social supports and other non-medical services to their members. About one-third of Medicare enrollees are in MA plans.
Paying for Meals and Rides
Today, these managed care plans must provide identical benefits to all their members regardless of health status, and services are limited to those that are “primarily health-related.” That means that fitness benefits are OK, but home-delivered meals or medical transportation are not. For many older adults with chronic conditions, a ride to the doctor or a hot meal to stave off malnutrition are crucial to their well-being. And such services may reduce the chances of emergency room visits or hospitalizations.
CHRONIC would change those rules. It would allow MA plans to target specific supplemental benefits to their high-need members with chronic conditions. And, according to a summary of the bill, it would permit benefits that “have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee and would not be limited to primarily health-related services.’
That doesn’t exactly say long-term supports and services, but it comes awfully close.
A Potential For Savings
The Bipartisan Policy Center, which has recommended many of the changes that found their way into CHRONIC, estimates that for an additional $5 per month, MA plans could provide a member with in-home meal delivery, non-emergency medical transportation, minor home modifications, and targeted case management services. In testimony to the Finance panel yesterday, BPC’s director of health policy, Katherine Hayes, put it cautiously but accurately: “If the provision of these non-Medicare-covered social supports reduced hospitalizations, emergency department visits, and other Medicare spending for the targeted group of enrollees, there is also a potential for savings.”
One example of how these programs can help those with chronic conditions is CAPABLE, a demonstration created by Sarah Szanton and her colleagues at Johns Hopkins. The program is built around a team that includes an occupational therapist, a nurse, and a handyman. They first determine a patient’s goals and then provide modest home repairs and modifications as well as assistive devices as needed. The results: Three-quarters of participants improved their ability to do activities such as walking, dressing, or bathing. However, the CAPABLE experiment was available only for those who are dually eligible for Medicare and Medicaid, not for the Medicare-only population.
We are learning that programs such as this can work. And they very likely can help those who receive only Medicare. Now, a bipartisan group of senators is taking some initial steps to open the door to those services.