ManagedCareSupplement3

A Primer on Managed Care: Multiple Chronic Conditions

a primary care provider (PCP), and for the ACO to provide incentives for members to obtain nec- essary primary care services; and √ Bringing primary care to the home through an expansion of Independence at Home and tele- health connections with PCPs. The most significant driver of medical uti- lization is not just the medical needs of benefi- ciaries with multiple chronic conditions, but also the functional limitations for which many of them need assistance to get through the day. People with multiple chronic conditions and functional limitations have twice the annual Medicare spending of people with multiple chronic conditions and no functional limita- tions (Tumlinson, 2018). Today, most of the funding for LTSS for people with substantial functional assistance needs comes through the Medicaid program. Many people with functional needs are either Medicaid-eligible or spend down to Medicaid eligibility. An equal number are Medicare ben- eficiaries who pay out-of-pocket due to having resources that make them ineligible for Medicaid. The Act should improve access to primary care, and expand opportunities for in-home supports and services. The other major focus of the Act is to encour- age an expansion of opportunities for Medicare beneficiaries with functional limitations to have coverage for LTSS needed to remain in their homes and communities and avoid unnecessary emergency room visits, hospitalizations, and nursing home admissions. It does this through: √ An expansion of Medicare Advantage (MA) Special Needs Plan (SNP) models for dual eligible beneficiaries that integrate Medicaid- covered LTSS with Medicare coverage and greatly improve care coordination and care management;

√ A new opportunity for MA plans to offer special supplemental benefits in Medicare that can provide specific non-medical services and supports targeted to people with specific chronic conditions; and √ An expanded opportunity for MA plans through value-based insurance design to provide services and supports that are shown to reduce unnecessary medical utilization and result in better outcomes for the individual. The greatest challenge for our healthcare sys- tem over the next few decades will be to meet the healthcare needs of a much older population without greatly expanding our institutional and highly specialized medical infrastructure and the outsized medical expenditures that go with it. Only when we aggressively create options to divert medical spending into more non-medi- cal services and supports to help maintain peo- ple with complex care needs in their homes and communities will we see a big improvement both in outcomes and reduction of avoidable medi- cal utilization. Such options are necessary for the nation’s growing aging population, and to do so without incurring major increases in medical infrastructure, personnel, and expenditures. A major driver of medical costs are unmet and poorly met needs that many people with severe chronic conditions have for assistance with fun- damental and basic daily tasks. Failing to provide this support system is a primary cause of older adults’ poor health and excessive medical utili- zation. We must shift our resources to build the capacity to support people where they live. The CHRONIC Care Act is, most impor- tantly, a recognition and acceptance by Con- gress of this challenge. It is a Medicare bill that expands the focus of Medicare beyond “medi- cal treatment only” and helps shift the center of gravity for people with chronic conditions toward the home and away from the revolving door of expensive, episodic, institutional care. Importance and Impact of the CHRONIC Care Act

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