For the last 3 decades, private health plans have played an increasingly important role in the Medicare program to help reduce costs, enhance quality, and improve choice. These plans, now known as Medicare Advantage (MA) or Medicare Part C plans, have undergone significant policy and structural changes since their inception to further meet the changing healthcare landscape and the increasing focus on value-based care. According to CMS administrator Seema Velma, 37% of Medicare beneficiaries now participate in Medicare Advantage, up from 15% just 2 decades ago, with further growth anticipated in 2020 especially as the senior population continues to grow nationwide.
Medicare Advantage plans usually provide supplemental benefits beyond what the tradition fee-for-service Medicare program offers, including dental, vision, prescription benefits, and out-of-pocket caps for enrollees. Prior to 2018, these supplemental benefits had to be “primarily health-related” according to CMS regulations. However, based on the new CMS guidance in 2018 and subsequent guidance, “primarily health-related” services have been expanded to allow Medicare Advantage plans a new level of discretion to offer a broader array of supplemental benefits and additional flexibility to offer innovative benefits and services that respond to the needs of their customers as long as these benefits are healthcare related. The goal is for MA plans to be able to design new benefit packages and provide services that will keep beneficiaries healthy and more independent, while contributing to lowering to the total cost of care.
A key focus area for CMS is social determinants and influencers of health (SDOH)—conditions in the places where people are born, live, learn, work, play, worship, and age, which affect a wide range of health, functioning, and quality-of-life outcomes. It is CMS’ goal that the new flexibilities will allow plans to address social determinants of health issues that can limit access to healthy foods, safe neighborhoods, housing, transportation, a good education, and timely medical care, to name a few.
Some services and benefits that MA plans offer include:
- Home modifications to accommodate patients with limited mobility
- Assistive devices for patients with chronic conditions to better help manage these chronic conditions, stay healthy longer, and keep healthcare costs down
- Transportation benefits, home-delivered meals, and personal care services
- Home air cleaners and carpet shampooing to reduce irritants that may trigger asthma attacks, nutrition programs for diabetics, and a plan to provide healthy foods or produce for patients with heart disease
With this new guidance, the following health plans and payers are seizing on the opportunity to add and/or expand benefit offerings to address SDOH issues:
- Anthem and many of the Anthem BCBS plans are taking a “whole person” approach to addressing SDOH issues in their MA beneficiaries, such as having home-delivered meals post-surgery, transportation for medical visits, a personal home helper, assistive devices, or time at an adult day care center—all with the hope of decreasing the physical and mental health impacts of isolation and loneliness
- Kaiser Permanente’s Thrive Local initiative will integrate traditional clinical care with mental healthcare and community services to provide comprehensive support for individuals struggling with food insecurity, housing issues, and personal safety concerns for its 12.3 million members
- Kaiser Permanente is contributing $25 million to the fund to extend the organization’s ongoing efforts to address homelessness, and Kaiser Permanente Northwest is funding a $5.1 million project that will take an “anything necessary” approach to achieving the goal of housing 300 homeless, medically vulnerable seniors by the end of 2020
- CVS is focusing on the social isolation SDOHs that especially afflicts older Americans and are associated with increased risk of depression, compromised immune systems, and cardiovascular disease—leading to decreased quality of life, lower health outcomes, and increased healthcare costs. CVS is leveraging community resources to connect identified patients to social programs
- Aetna has developed a social isolation index to help understand how isolation and loneliness is affecting its Medicare populations, then referring at-risk patients to community-based programs to support the SDOH issues
Data recently published by UnitedHealth demonstrated that MA plan holders saved nearly 40% more compared to fee-for-service Medicare beneficiaries. This is being seen as further validation to expand the MA programs with the aim to adopt supplemental benefits that target social determinants of health, such as food stability.
As payers and health systems roll out expanded programs and initiatives focused on SDOH, they are looking to tangibly demonstrate the value and outcomes of these interventions by leveraging concrete measures and data. They are also looking to partner with other entities in the healthcare ecosystem, including community centers, national and state governments, and pharmaceutical manufacturers, to explore new and innovative solutions in the SDOH space that can be successfully scaled, spread, and sustained over time—in hopes of attaining better patient outcomes, better population health, and lower total healthcare costs.