GENERATIONS – Journal of the American Society on Aging
to services that are “primarily health-related” and benefit offerings must be approved by CMS. CMS recently expanded the definition of allowable benefits to define “primarily health- related” to include any service that allows for the diagnosis, prevention, or treatment of an ill- ness or injury; that compensates for physical impairments; that ameliorates the functional/ psychological impact of injuries or health con- ditions; or that reduces avoidable emergency or healthcare utilization. This has meant new opportunities for plans to offer targeted populations caregiver sup- port, in-home modifications, direct care in the home, and other services that may be expected to compensate for physical impairments, address impact of injuries or health conditions, or reduce avoidable hospital use. This definition of allowable supplemen- tal benefits will be further expanded in 2020, as a result of congressional action intended to address the needs of individuals with chronic conditions. This action is in response to the rec- ognition of the role social determinants of health play in achieving better patient outcomes. Lack of transportation and in-home supports, food insecurity, and functional impairments all have been seen to have an impact on a person’s capa city to improve his or her health status. Unlike traditional Medicare, MA can identify popula- tions of beneficiaries in need and deliver these additional benefits to address the social deter minants of health. These new efforts will be tested in the years ahead, and can yield valuable lessons for reform- ing MA and, possibly, traditional Medicare. It remains to be seen if the potential impacts of these efforts in transforming financing, benefits, services, more preventive services and screenings, and had better outcomes. MA beneficiaries with chronic conditions used fewer high-cost
and care delivery can meet the needs of Medi- care beneficiaries, particularly those having complex needs.
MA Shows Outcomes Improvement in Chronic Conditions
The opportunities inherent in MA to improve healthcare and outcomes at the same or lower costs than traditional Medicare have been reported in numerous small-scale studies over the years. However, it was not until July 2018 that a research report from Avalere Health offered findings from a large-scale national com- parative analysis that found outcomes in MA were better for high-need, chronically ill benefi- ciaries than in traditional Medicare (Mendelson, Teigland, and Creighton, 2018). Sponsored by Better Medicare Alliance, the research compared demographic, cost, utili- zation, and quality metrics for 1.6 million MA beneficiaries and 1.2 million beneficiaries in traditional Medicare with one of the selected chronic conditions of hypertension, hyperlipid- emia, and diabetes. While the two study populations had similar demographic profiles, MA had a higher propor- tion of beneficiaries with clinical and social risk factors shown to affect outcomes and cost. This included a 15 percent higher likelihood of being dually eligible, a 57 percent higher rate of serious mental illness, and a 16 percent higher rate of substance abuse. Despite this higher proportion of risk factors, MA beneficiaries with chronic conditions expe- rienced lower use of high-cost services, higher rates of preventive services and screenings, and better outcomes. Specifically, for the study population, MA achieved 23 percent fewer inpatient hospital stays, 33 percent fewer emergency room visits, and a 29 percent lower rate of potentially avoid- able hospitalizations. They also experienced a 13 percent higher rate of LDL (low-density lipopro- tein) cholesterol testing and a 5 percent higher rate of breast cancer screening.
22 | Spring 2019
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