by Jean Rush, Independent Board Member, former EVP Government Markets, Highmark

December 2019 – In 2019, CMS provided Medicare Advantage plans with greater flexibility in the definition of “supplemental benefits,” allowing these benefits if they “compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.“   In essence, this new guidance allows health plans to provide benefits that will improve the quality of life and health outcomes for their senior members by providing practical support with activities of daily living.

Why is this important? Consider Bill and Mary, a 90-year-old couple who have been happily married for 65 years. They continue to live together in their own home but a recent fall has led to reduced abilities to shop, cook, and clean, which could increase the risk of future hospitalizations or emergency room visits — clearly not what they had hoped for in their golden years.  However, if these new supplemental benefits are covered by their Medicare Advantage plan, they may be able to secure assistance with these types of activities through Personal Care Attendants, allowing them to remain independent at home.

Personal Care Attendants or Home Care Aides provide non-clinical support for activities of daily living (i.e., cooking, shopping, transportation, cleaning) that enable seniors and people with disabilities to remain safely in their homes. A part of Medicaid plans for many years (under Long Term Services and Support benefits), Personal Care Attendants have assisted patients with multiple chronic conditions and have produced the following tangible benefits:

  • Reduced inpatient admissions and re-admissions
  • Reduction in emergency room utilization
  • Improvement in rates of physician follow-ups after an episode of care
  • Reduced total medical spend

In one particular study involving low-income seniors, inpatient admissions were down 40%, readmissions were down 50%, and emergency room utilization decreased by 35%.  In a different study involving low-income seniors, emergency room visits dropped by 13% and inpatient stays dropped by 9%.  While this may not be representative of all populations, it is clear that Personal Care Attendants can make a difference.

In addition to providing needed in-home services, these Personal Care Attendants are trained to detect  “changes in the patient’s condition,” and to notify the Care Manager at the patient’s managed care company  of these changes so that clinical interventions or care can be introduced. In one example, a senior complained to her Personal Care Attendant that she was feeling weak and lacking energy.  She also noted that the cost of her prescriptions had risen dramatically.  The Personal Care Attendant contacted the Care Manager at the managed care organization who arranged for a nurse to perform a medication inventory.  The Nurse identified the fact that the patient was receiving medications from two separate physicians.  After collaborating with both physicians, the patient’s medications were reduced from 29 to 9 and she began feeling well again. This intervention by the Personal Care Attendant in partnership with the patient’s managed care plan avoided adverse drug interaction, reduced the patient’s medication costs, and prevented a potential emergency room visit or inpatient stay.

So where are Medicare Advantage companies with adding these new supplemental benefits to their plan designs?  Well, as of 2019 they are just “dipping their toe in the water.”  Always wary of the potential for adverse risk selection, Medicare Advantage companies are introducing some limited benefits to see how they work. Those companies who have had previous experience with Personal Care Attendants through their Medicaid plans have a better understanding of the opportunities these new benefits provide.

So how can Medicare Advantage plans get started offering these benefits and seeing firsthand how Personal Care Attendants can positively impact their members’ outcomes?  One idea is to target services for members with specific conditions where the addition of in-home personal care services will enhance the treatment plan, reduce utilization of more expensive treatment options, and avoid alternative site placement such as skilled rehab facilities.  Examples of specific conditions that could be targeted by Medicare Advantage plans include joint replacement surgery, congestive heart failure, chronic obstructive pulmonary disease (COPD), or chronic urinary tract infections (UTI).

As 10,000+ seniors are aging into Medicare every day, it will become critically important for the healthcare industry to figure out how to help these seniors live longer, healthier lives at home.  New supplemental benefits such as Personal Care Attendants will become one of the critical tools for managing this population and helping to improve both quality of life and health outcomes.

About the Author

Jean Rush is an experienced CEO and Director with a focus in government, commercial, and international healthcare.  She was recently the Executive Vice President of Government Markets at Highmark where she had P&L responsibility for Highmark’s $7B highly regulated government businesses, including Medicare, Medicaid, Individual and Small Group markets.  Prior to Highmark, Jean held various leadership positions at both Centene and Cigna including CEO of Kentucky Spirit Health plan and President of Cigna Government Services.

Jean currently serves on the Board of Directors for Addus Homecare(NASDAQ: ADUS), Eventus  WholeHealth ,  Women Business Leaders in the US Healthcare Industry (WBL), and  Little Spurs Pediatric Urgent Care.   She also serves on the Advisory Boards for Aarete and Vaxcare, and is a member of both the National Association of Corporate Directors (NACD) as well as Women Corporate Directors (WCD).

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