Could ACO design changes be needed to incentivize a focus on long-term payoffs from the utilization of social supports?


April 25—Implementation of four social services could reduce costs for Medicare enrollees who have three or more chronic conditions, but there’s little appetite in Washington, D.C., for more spending on such services. So a bipartisan policy group backed some no-cost policy changes to encourage coverage.

The provision of four types of social supports—meal delivery, minor home modifications, non-emergent medical transportation, and targeted case management—could provide big savings through reductions in hospitalization and other institutional care, according to a new report from the Bipartisan Policy Center (BPC). But a February report from the same group found that Medicare’s payment rules and regulations have created “significant” barriers for Medicare Advantage (MA) plans and accountable care organizations (ACOs) that fund such care.

The BPC outlined steps—short of new funding—that policy makers could take to encourage MA plans and ACOs to cover the cost of those services:

  • Congress should authorize modification of the MA uniform-benefit requirement to allow plans to direct non-Medicare-covered health-related social supports and services to certain plan enrollees.
  • The Centers for Medicare & Medicaid Services (CMS) should waive MA requirements that supplemental benefits be primarily health-related.
  • CMS should grant ACO waivers for free health-related supports and services “that optimize health or functional status.”

“We believe [taking these steps] would not only improve care but lower the beneficiaries’ medical costs while also slowing expenditures from the public purse,” G. William Hoagland, senior vice president for BPC, said during a discussion of the report.

Although the 3.7 million Medicare enrollees targeted by the proposed policy changes are not the sickest and poorest in the program—compared with those who are dually eligible for Medicare and Medicaid—they nonetheless consume twice the annual spending of the average Medicare enrollee and struggle to fund such supports on their own, according to Melinda Abrams, a vice president for the Commonwealth Fund.

“If we can improve the financing for home and community-based care, it will not only help the beneficiaries with multiple chronic conditions and functional limitations but it will also help their families,” Abrams said.

Some of the policy changes also are being pushed by Congress. For instance, on April 6 Sen. Orrin Hatch (R-Utah) reintroduced the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017, which would allow MA plans to offer a wider array of supplemental benefits to certain chronically ill enrollees beginning in 2020.

Challenges Ahead

Although such community services have drawn increasing attention as a way to potentially reduce healthcare costs by helping beneficiaries avoid subsequent institutional care, proponents acknowledge that there is inadequate data to definitively draw such conclusions.

“There is an incredible research gap here around the relationship between spending on social services and supports—long-term services and supports—and spending in health care,” said Anne Tumlinson, a researcher on long-term care financing.

Nora Super, chief of Programs and Services at the National Association of Area Agencies on Aging, said her organization’s anecdotal experience, accrued over decades, supports the idea that such services can help reduce other healthcare costs. But the organization lacks the funding for published research.

“We believe that it will work, but we don’t have the data that proves it really,” Super said.

Mara McDermott, vice president of Federal Affairs for CAPG, which represents practices operating under capitated models, said some of her member-practices have found overall savings when they used capitated funding to provide non-emergent medical transportation programs for patients.

Not all of the limited research has been positive. A recent study published in Health Affairs examined some of the most promising interventions funded through $1 billion in federal grants since 2012. The researchers found that nonclinical interventions aimed at “socially fragile patients” provided no savings.

Such social supports also have drawn pushback from critics who worry that MA plans would offer them as inducements to garner more patients. McDermott noted that the BPC report urges policies that ensure MA plans could not use marketing materials to tout that all enrollees would get personal care assistants and other such benefits. Limiting the provision of such supports to specific patients is key to offsetting other spending, policy advocates said.

Although such supports have had a significantly positive impact among MA plans, McDermott noted that their prospects are less certain among ACO plans because patients in the latter group are free to move in and out of those programs throughout the year. For that matter, the long-term focus of MA plans also needs to be increased to spur a greater interest in such social supports, said Phil Ellis, PhD, senior research director at Acumen. If MA enrollees were committed to a single plan for multiple years, they would be more invested in such benefits, which prevent spending over many years, Ellis said.

Bigger Demand

Sachin Jain, MD, president and CEO of CareMore Health System, said he wished Medicare funding were available for more than just the four types of services suggested in the BPC report. For instance, his system has found that personal care assistants who provide in-home nail cutting and patient washing can identify changes and warning signs in time to allow patients to avoid costly post-acute care stays.

Tumlinson described the four types of community supports as “illustrative,” while others noted more research also was needed to identify the most cost-effective supports.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, April 25, 2017