A powerful bipartisan group of U.S. senators wants to improve medical care for older Americans with chronic disease. By doing so, they are taking an important step in improving the health and quality of life of these seniors.
But so far at least, they are focusing on only half the problem. While older people with chronic conditions do need improved medical care, they also need better social supports, personal assistance, access to services such as transportation, and safe and affordable housing. Improving delivery of medical care without including social supports is like pumping air in a flat tire without first fixing the puncture.
First the good news: This week, Senate Finance Committee Chair Orrin Hatch (R-UT) and Ron Wyden (D-OR) held the latest in a series of hearings on the need to improve Medicare for those with multiple chronic illnesses. They also announced that they’ve asked senators Mark Warner (D-VA) and Johnny Isakson (R-GA) to develop specific proposals.
These lawmakers seem well aware of the problem. About 14 percent of Medicare recipients have 6 or more chronic conditions, but they represent almost half of all the program’s costs.
But these numbers miss a key factor. Those high cost enrollees don’t just have multiple medical conditions. They also have functional limitations and often cognitive impairment. And often, it is the combination that drives high costs, not chronic illness alone.
In 2011, my Urban Institute colleague Judy Feder and Harriet Komisar (now at AARP) found that on average, Medicare spent almost $16,000 on this population in 2006, twice as much as it spent on those who had multiple chronic disease but did not need assistance with daily activities such as bathing, eating, or going to the bathroom.
Medicare spends nearly twice as much for these very frail enrollees on hospital care, almost nine times as much for care in skilled nursing facilities, and almost six times as much for home health as those with chronic conditions only. About 40 percent of those costs went to hospital and skilled nursing facility care that might have been unnecessary had they had sufficient help with personal assistance.
In other words, without the services and supports to help address their functional limitations, even better coordinated medical care won’t make huge improvements in their quality of life, and it may not save much money.
Imagine a senior with heart disease, diabetes, and arthritis. Today, fee-for-service Medicare pays specialists to treat each of those conditions but does little to coordinate this complex medical care. The patient gets multiple tests, a dozen or more drugs that may interact poorly with one another, and must make endless trips to her various doctors.
The result of all of this is ineffective treatment, repeated visits to the hospital, and a real risk of harm.
To their credit, Hatch and Wyden want to improve incentives for Medicare providers to better coordinate care. At yesterday’s hearing, Dr. Patrick Conway, medical director at the Centers for Medicare & Medicaid Services, described the many ways his agency is supporting experiments aimed at doing this. They include Accountable Care Organizations, where doctors and hospitals create formal financial arrangements to treat episodes of care for a fixed Medicare payment; and bundled payments, a less formal structure where providers combine services and share payment for the care of certain patients.
At the same time Medicare Advantage, the program’s managed care model, has gone mainstream. Nearly one-third of all beneficiaries have chosen MA plans rather than traditional Medicare.
But remember that senior with heart disease, diabetes, and arthritis. Even with the best, well-coordinated medical treatments, how well is she going to do without an aide to help her get started in the morning, assistance taking her many meds, or a ride to the doctor? Without a grab bar in her shower, she could very well fall. And with very few exceptions, none of Medicare’s managed care models provide any of those services.
It isn’t enough to simply say Medicare doesn’t pay for any of that. Hatch, Wyden, and their colleagues need to think creatively about how to combine medical care with long-term supports and services. Maybe it happens inside Medicare, maybe not. But they work to make it happen.
There are better ideas.
In an article in the current issue of The Gerontologist, Dr. Joanne Lynn and Anne Montgomery of the Altarum Institute describe one model. Called Medicaring Accountable Care Communities, their model brings together medical and social services providers around a single comprehensive care plan. Lynn and Montgomery estimate the program could be self-financing by reallocating medical cost savings to help pay for supportive services.
In Massachusetts, the Commonwealth Care Alliance operates a Medicare Advantage special needs plan called senior care options that has successfully combined medical care with home supportive services. And hospice is a great model for coordinated medical and social care.
Ideas are out there. The senators need to think more creatively about how to provide all the care seniors with chronic conditions need, not just how to improve their medical treatment.