The Promise of Integrated Care Through Medicare Advantage

A recent commentary in the New England Journal of Medicine described how recent legislative changes to how Medicare Advantage plans can integrate medical and non-medical services could improve integrated care.

Amber Willink, PhD, of the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, and Eva H DuGoff, PhD, of the Department of Health Services Administration, University of Maryland, explained that the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, that was passed as part of the 2018 US budget reform, changed how Medicare Advantage integrates medical and non-medical services.

“The law gives Medicare Advantage plans two opportunities to increase the flexibility of their benefit offerings starting in 2020,” they wrote. “First, it allows plans to offer nonmedical supplementary benefits to better address the health of people with chronic illness. And second, it eliminates the mandate to provide uniform benefits, allowing plans to tailor their benefits to specific chronically ill subgroups of patients.”

The CHRONIC act changed the requirement that all Medicare Advantage plan services must be primarily related to health. The new definition of Medicare Advantage allows plans to include long-term services and supports, like “hearing aids to scooters, adapted utensils, environmental modifications, meal or transportation services, and personal care services,” according to Drs Willink and DuGoff.

They explained that the law will allow Medicare Advantage plan administrators to use innovative models of care to support the non-medical needs of Medicare patients. They said that one possible model, the Community Aging in Place–Advancing Better Living for Elders program, combines a clinical team with a occupational therapist and a repair man for low-income adults. This program helps seniors live in their homes and communities in a safer and more supported environment. CMS found that this program reduced per patient costs by $2765, compared with normal care.

However, Drs Willink and DuGoff noted that these changes have the potential to affect risk election, which could negatively impact care integration.

“The promise of better outcomes and significant cost savings as a result of reduced hospitalizations and emergency department visits should give the plans opportunities to better serve high-need beneficiaries,” they wrote. “Yet these changes may also attract the sickest beneficiaries who require the costliest care to switch from traditional Medicare to Medicare Advantage.”

They explained that as a result, Medicare Advantage plans may decide not to broaden their integrated care model offerings, or they may ask CMS to include functional impairments in beneficiaries’ risk scores.

Drs Willink and DuGoff proposed the development of integrated care organizations, that function like ACOs, but with more emphasis on finding ways to serve long-term services and support.

They concluded that allowing Medicare Advantage plans to integrate some supportive non-medical services could improve outcomes for beneficiaries and reduce Medicare spending.

“Historically, the exclusion of long-term services and support from the Medicare program has resulted in the artificial separation of medical needs from general health and well-being, to the detriment of beneficiaries,” Drs Willink and DuGoff wrote. “Allowing Medicare Advantage plans greater flexibility to include nonmedical services without putting them at risk for all long-term services and support (for instance, costly nursing homes) may tackle long-term services and support needs in a way that wasn’t previously possible without significantly increasing Medicare spending.”

—David Costill

For articles by IH Executive, click here

For articles by First Report Managed Care, click here