A Step Down The Road To Better Medicare For Those With Chronic Disease

Last week, the Senate quietly and unanimously passed a bill that would improve some Medicare benefits for people with chronic disease. The measure would do many good things but the most important is this: It would take important steps toward breaking down the wall between medical treatment and non-medical supports and services in Medicare, beginning a process that would make it much easier for frail seniors to receive the right care when they need it.

The bipartisan measure, called the called the Creating High-Quality Results and Outcomes Necessary to Improve Chronic  Care (CHRONIC) Act of 2017, was sponsored by Senate Finance Committee Chair Orrin Hatch (R-UT) and top committee Democrat Ron Wyden (D-OR) as well as panel members  Johnny Isakson (R-GA) and John Warner (D-VA). It would give Medicare managed care plans new flexibility to  better organize care and provide non-medical supports and services. It would also expand a temporary program aimed at providing team-based care at home for people with complex medical conditions, and increase the use of telehealth services.

Medicare does not pay

Today, with a few narrow exceptions, Medicare does not pay for long-term supports and services such as home health aides, home modifications, rides to the doctor and the like. It provides limited home health services only after someone has been hospitalized for three days, and only a short period of time.

While many consumers believe Medicare does provide these long-term benefits, it generally does not. As a result, a frail senior or a younger person with disabilities must navigate multiple systems and payers to assemble the care they need. It is a nightmare. Millions of people fall through the cracks. Some die as a result.

Medicaid does pay for some of these services, but only if you are very frail and impoverished. A middle-income person who has say, diabetes and congestive heart failure, is on her own.

The bill would open the door to important new Medicare supports and services, but only for those in managed care.

Special Needs plans

It would make permanent some managed care plans called Special Needs Plans (SNPs). About 2.4 million people are enrolled in these programs, over 80 percent in what are known as D-SNPs that benefit  people eligible for both Medicare and Medicaid (the ‘D “refers to dual eligibles).

SNPs have been operating as temporary programs for years, with mixed results. Some forms have been quite successful while others have failed. The bill attempts to address some of the problems with SNPs by requiring them to improve care coordination, including coordinating Medicare medical care with Medicaid long-term supports and services. It gives states broad flexibility in setting standards for D-SNPs and strengthens the appeals process for enrollees.

The SNP provisions could be a lot stronger but the bill at nudges these plans toward better, more coordinated care.

The biggest change would apply to the far more common Medicare Advantage managed care plans. They cover about one-third of all Medicare enrollees but are barred from offering non-medical services.

Medicare Advantage

Today, these managed care plans must provide identical benefits to all their members regardless of health status, and limited services to those that are “primarily health-related.” That means it is illegal to offer home-delivered meals or medical transportation. For an older adult with chronic conditions, a ride to the doctor or a hot meal to stave off malnutrition can reduce emergency room visits or hospitalizations.

CHRONIC would allow MA plans to target specific supplemental benefits to their high-need members with chronic conditions. And, according to the official legislative summary of the bill, “These supplemental benefits would be defined as those 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.”  In other words, long-term supports and services.

Game changer

This is potentially a game-changer, at least for MA plans. The bill doesn’t require them to offer these benefits and insurers must still develop structures to deliver supports and services to members who need them. This will take time. But fully integrating medical treatment and supports and services in one insurance plan creates tremendous opportunities for insurers, providers, and especially, participants.

The new benefits are limited only to MA plans. Seniors in fee-for-service Medicare would still be ineligible for long-term services and supports. In the long run, this is not a sustainable situation. Eventually, Congress will either include long-term care in traditional fee-for service Medicare or the program will eventually whither.

For now, there are no signs that the House will pass CHRONIC. But unanimous bipartisan Senate approval is an important step forward.

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