Medicare Allows More Benefits for Chronically Ill, Aiming to Improve Care for Millions
Posted June 24, 2018 7:11 p.m. EDT
WASHINGTON — Congress and the Trump administration are revamping Medicare to provide extra benefits to people with multiple chronic illnesses, a significant departure from the program’s traditional focus that aims to create a new model of care for millions of older Americans.
The changes — reflected in a new law and in official guidance from the Department of Health and Human Services — tackle a vexing and costly problem in American health care: how to deal with long-term illnesses that can build on one another, and the social factors outside the reach of traditional medicine that can contribute to them, like nutrition, transportation and housing.
To that end, the additional benefits can include social and medical services, home improvements like wheelchair ramps, transportation to doctor’s offices and home delivery of hot meals.
The new law is a rare instance of bipartisan cooperation on a major policy initiative, embraced by members of Congress from both parties. The changes are also supported by Medicare officials and insurance companies that operate the fast-growing Medicare Advantage plans serving one-third of the 60 million Medicare beneficiaries.
“This is a way to update and strengthen Medicare,” said Sen. Ron Wyden, D-Ore. an architect of the law, the Chronic Care Act, which was included in budget legislation signed recently by President Donald Trump. “It begins a transformational change in the way Medicare works for seniors who suffer from chronic conditions. More of them will be able to receive care at home, so they can stay independent and out of the hospital.”
Half of Medicare patients are treated for five or more chronic conditions each year, and they account for three-fourths of Medicare spending, according to Kenneth E. Thorpe, chairman of the health policy department at Emory University.
Under the new law and Trump administration policy, most of the new benefits will be reserved for Medicare Advantage plans, which will be able to offer additional benefits tailored to the needs of people with conditions like diabetes, Alzheimer’s, Parkinson’s disease, heart failure, rheumatoid arthritis and some types of cancer.
“This is a big win for patients,” said Seema Verma, administrator of the Centers for Medicare and Medicaid Services.
Officials hope that combining social and medical services will produce better outcomes for patients and save money for Medicare.
“An inexpensive railing in the bath can avoid a fall that can cause a hip fracture and potential complications,” said David Sayen, who worked at the Medicare agency for 37 years. Treatment for a broken hip, including hospital care and follow-up services, can easily cost Medicare more than $20,000, and the costs are much higher in some regions than in others.
Medicare plans could also reduce copayments and deductibles for people who receive treatment for a particular medical condition from certain recommended doctors, hospitals or other health care providers.
Sayen said the new federal policy gave health plans “a whole new toolbox to address social determinants of health.”
Although Medicare Advantage plans will wield most of the tools, their experience will be useful to policymakers who want to extend similar benefits to people in the rest of Medicare.
Medicare Advantage plans must cover all the services the original Medicare program covers except hospice care, and many offer extra benefits as well. Until now, the government has generally required each Medicare plan to offer the same benefits with the same cost-sharing to all beneficiaries.
The Trump administration has reinterpreted the “uniformity requirement” to allow different supplemental benefits for people with different medical needs. Congress went further and allowed Medicare officials to waive those requirements for patients with chronic illnesses.
Moreover, Congress allowed Medicare plans to offer a wider array of supplemental benefits to the chronically ill, eliminating the current requirement that the extra benefits must be “primarily health-related.”
John G. Lovelace, president of government programs at UPMC Health Plan in Pittsburgh, said the extra benefits could include visits by a personal assistant to help with bathing and dressing; visits by a nurse or a pharmacist to make sure a Medicare beneficiary with a dozen prescriptions is taking the right medicines; and special supervised housing for a person with dementia who cannot be left alone.
John K. Gorman, a former Medicare official who is a consultant to many insurers, predicted rapid growth in the use of high-tech pill dispensing machines, remote monitoring of homebound people and telehealth services to connect patients with doctors hundreds of miles away.
The Chronic Care Act provides new financial incentives for the use of telehealth services, including coverage for stroke patients in traditional Medicare as well as Medicare Advantage. Sue Nelson, a vice president of the American Heart Association, said these provisions “could help tens of thousands of stroke patients every year, increasing survival rates and reducing disability and the need for rehabilitation and nursing home care.”
Many hospitals do not have stroke experts readily available. But under the new law, Medicare will pay for consultation with a neurologist at a distant location, using special medical equipment for videoconferencing. The doctor can review CT scan images and recommend treatments, including the use of highly effective clot-busting drugs.
Dr. Lee H. Schwamm, chief of stroke services at Massachusetts General Hospital, said Medicare could also pay neurologists to evaluate patients with stroke symptoms while they were in an ambulance. The doctors could then direct paramedics to the most appropriate hospital.
David M. Certner, the legislative policy director of AARP, the lobby for older Americans, said his group supports the idea of allowing greater coverage for supplemental benefits, including nonmedical services that can improve care. “We believe such coverage should be available under both Medicare Advantage and traditional Medicare,” he said.
Defining eligibility and limiting the scope of benefits in traditional Medicare could be a challenge. But Eva H. DuGoff, a health services researcher at the University of Maryland, said, “We can learn from Medicare Advantage plans which services have the most benefits for which populations.”
Sarah L. Szanton, a professor at Johns Hopkins University, developed an experimental program that provided 1,000 low-income Medicare beneficiaries with extra services, including several visits from a nurse, an occupational therapist and a handyman who did minor home repairs and modifications. These services, she said, saved Medicare an average of $22,000 a year for each beneficiary, keeping people safe at home and avoiding hospital and nursing home admissions. Hundreds of thousands of people miss doctor’s appointments each year because they do not have reliable transportation.
Lauren Belive, director of federal government relations for Lyft, the ride-sharing service, said her company was eager to meet that need for Medicare patients.
Lyft formed a partnership last year with the Blue Cross Blue Shield Association to provide rides to people who have health insurance but no convenient way to get to doctors and clinics.
Nonprofit groups like Meals on Wheels are also prepared to play a larger role, not only delivering meals but also checking on the health and safety of frail older people and providing potentially useful clinical information to health plans.
“We can be the eyes and ears inside the home to observe if there’s a change in the condition of the seniors we serve,” said Ellie Hollander, president and chief executive of Meals on Wheels America.
The Chronic Care Act was a bipartisan project from the start, conceived by Wyden and the chairman of the Senate Finance Committee, Sen. Orrin G. Hatch, R-Utah, working with Sens. Johnny Isakson, R-Ga., and Mark Warner, D-Va.