GENERATIONS – Journal of the American Society on Aging
has been important to improving outcomes and lowering the costs in chronic care models has been the ability to target benefits to meet the unique needs of patients (BPC, 2017). As such, CMS should consider giving plans the flexibility to tailor benefits to a greater degree than diagno- sis alone allows. ‘Studies have consistently shown that functional status plays a significant role in determining healthcare costs.’ A strong argument can be made for per- mitting targeting within a diagnosis, because patients with the same diagnosis do not neces- sarily have the same need for services. For ex ample, two patients with a diagnosis of chronic heart failure might be in very different stages of the disease and have significant differences in functional status. A plan might reasonably expect that providing a stair lift for someone who is no longer able to go up and down stairs unassisted would help maintain health and functional sta- tus, and allow that person to remain independent in his or her home for a longer period of time. If a plan were required to provide the same benefit to an enrollee with chronic heart failure who can climb stairs, a stair lift would not be an effective use of plan resources. Studies have consistently shown that func- tional status plays a significant role in deter- mining healthcare costs (Ingber, Kautter, and Pope, 2008; Rodriguez et al., 2014). In addi- tion to diagnosis, CMS could incorporate func- tional assessment as a tool to establish eligibility
for supplemental benefits. Plans involved in the delivery of Medicaid LTSS, including MA plans, have experience in performing functional assess- ments covering items and services based on a person’s ability to perform activities of daily liv- ing—such as the ability to prepare meals, or to eat, bathe, or dress without assistance. Func- tional assessment has played a role in Medicare reimbursement and in assessing patient out- comes, and while Medicare does not use a federal uniform functional assessment tool, since 2013, outpatient therapy providers have been required to report functional assessment (CMS, 2018c). Incorporating functional assessment can better align patient needs and benefits. Looking Ahead As CMS implements chronic care provisions, it is important to require plans to demonstrate the success or failure of implementing supplemental benefits. Skeptics of MA expressed concern that plans will use supplemental benefits as a tool to increase plan enrollment, rather than to improve the care of patients with chronic conditions. Failure to document supplemental benefits and patient outcomes could lead to increased con- gressional oversight and efforts to reduce plan flexibility in the years ahead. Building a strong evidentiary base will not only allay concerns over plans’ motivations, but also could lay the ground- work for benefit expansion in other Medicare payment and delivery models, and in areas of the country where MA plans are not available.
Katherine Hayes, J.D., is director of health policy at the Bipartisan Policy Center in Washington, D.C.
References Bipartisan Budget Act (BBA). 2018. H.R. 1892. 115 th Cong. Bipartisan Chronic Care Working Group. 2015. Policy Options Docu- ment. Washington, DC: U.S. Sen- ate Committee on Finance. tinyurl. com/ybqxa59u. Retrieved October 29, 2018.
Bipartisan Policy Center (BPC). 2016. Delivery System Reform: Improving Care for Individuals Dually Eligible for Medicare and Medicaid (report from Health Project). tinyurl.com/ychcpqla. Retrieved December 3, 2018.
BPC. 2017. Update on Demonstra- tions for Dual-Eligible Medicare- Medicaid Beneficiaries (report from Health Project). tinyurl.com/ ybu5ohu6. Retrieved October 29, 2018.
86 | Spring 2019
Made with FlippingBook Learn more on our blog