The federal agency that operates Medicare, the Centers for Medicare and Medicaid Services (CMS), is finally recognizing what families have known for, well, thousands of years: Family members are the bedrock of the system of care for frail older adults and younger people with disabilities. And the agency is taking some important steps to help them.
Some proposals will provide valuable support. Others less so. But the key is that, for the first time, Medicare will pay doctors and other providers to deliver critical support to the families of people with certain medical conditions.
Medicare Advantage and other managed care models have been able to provide some of these supports. But for years, CMS took the view that fee-for-service Medicare could pay only for services offered directly to beneficiaries, and not to the family members caring for them. That is about to change.
The agency would:
- Pay Medicare providers, including physicians, some nurses, and therapists to train family caregivers.
- Pay for a social needs assessment and care navigation for people with certain conditions.
- Create an integrated care model for people with dementia and their families.
Let’s look at each.
First, CMS would create a billing code to pay Medicare providers, including physicians; nurse practitioners; physician assistants; and speech, physical and occupational therapists, to train family members who are caring for their loved ones. The new payment would begin next year and appears to permit both individual and group training.
This is a great idea, and long overdue. Today, families are expected to provide often-complex care for patients living at home with little or no training. They are supposed to magically know how to do everything from wound care to transferring a patient from a bed to a chair.
Training would be a huge benefit. But who really will do it? The vast majority of physicians know little about many of these skills and have neither the time nor the ability to train others. Docs may bill for it but the best work is likely to be done by nurses or therapists.
The proposal also appears to contemplate that this training will occur in medical offices, much like all Medicare Part B services. But this also defies real world experience. Overburdened family members are not likely to come to a doctor’s office or a physical therapy center to get this training.
The new payment model should allow for doctors to outsource this work to community-based organizations, such as adult day and senior centers, and similar groups. Problem is: These generally are not Medicare providers. I hope CMS will figure out a way to make this work. (Full disclosure, I am an unpaid board member of a community-based organization that could provide some of these services).
The second initiative would allow Medicare to pay for a health-related social needs assessment and, just as important, assistance with care navigation. Importantly, this new payment rule would allow physicians to partner with non-medical providers including community-based social service organizations and community health workers who may be best able to do this work.
But it is limited, at least for now, to certain “high-risk conditions.” CMS should define this as broadly as possible, focusing on those diseases where patients can benefit most from a needs assessment and care navigation.
Integrated Dementia Care
The third reform would be targeted specifically to families caring for loved ones with dementia. Guiding an Improved Dementia Experience (GUIDE) is an eight-year demonstration that aims to deliver a package of care coordination and management, caregiver education and support, and respite services.
This program, scheduled to begin a year from now, is exactly the kind of fully-coordinated care model that people with chronic conditions need. And, as I recently wrote, some of the nation’s most creative integrated care programs for people with dementia have been stymied because Medicare (and Medicaid) would not pay for them. This has the potential to change that.
The dementia care model seems wonderful. But as with the navigation model for people only with specified conditions, why is CMS limiting it only to those with dementia? Medicare should be thinking about such a model for all serious chronic conditions.
The Importance Of Family Caregivers
Many questions remain. How much will Medicare pay for these services? How frequently can they be offered? Who is a family caregiver? Will medical practices be willing to participate, something many have not done with other Medicare alternative payment models.
Despite their limitations, these initiatives by the Biden Administration are a huge step forward. They promise to break down some of the biggest barriers to effective family caregiving and may help people with chronic conditions to age at home for longer. Most important, they say that family caregivers matter.