MA Beneficiaries See Nearly 20% Fewer Home Health Days Than Traditional Medicare Peers

Under the Trump administration, federal health care policymakers have long been vocal about the ability of Medicare Advantage (MA) to lower costs and improve outcomes among vulnerable populations.

A recent report from the Washington, D.C.-based Better Medicare Alliance (BMA) and consulting firm Avalere Health is now putting hard numbers on that claim, particularly around home health services and post-acute care.

“The hallmark features of Medicare Advantage — risk-adjusted capitated payment, strong value-based performance incentives and flexibility in benefit design — enable health plans to offer care management interventions that meet complex care needs of vulnerable beneficiaries in ways that produce robust positive outcomes and greater value for high need, high cost beneficiaries,” the report states.

To study cost and outcomes differences between MA and traditional fee-for-service (FFS) Medicare, Avalere and BMA analyzed data tied to more than 1.4 million MA enrollees and 7.9 million FSS beneficiaries. Researchers pulled data from 2015 to 2017.

Broadly, the findings show that MA enrollees spend far fewer days on home health services compared to their FSS peers. For every 1,000 individuals, home health days on service were nearly 20% lower in MA than in traditional Medicare, with an even greater difference among certain subpopulations.

For every 1,000 individuals under the age of 65 living with a disability, for example, home health days on service were about 27% lower in MA than FFS. For every 1,000 individuals living with a major complex and chronic condition, home health days on service were again 27% lower.

The smallest gap in home health agency days came in the frail elderly subpopulation, according to the report. For every 1,000 frail and elderly individuals, home health days on service were about 10% lower in MA than in traditional Medicare.

“The data … show that home health utilization is lower for all three populations in Medicare Advantage compared to traditional FFS Medicare,” the report notes. “One possible explanation is that inappropriate use of these services is minimized in Medicare Advantage relative to traditional FFS Medicare, but further research is needed to evaluate differences in use of home health services.”

High-need, high-cost MA beneficiaries had lower rates of post-acute utilization across all settings compared with those in traditional Medicare. Skilled nursing facility (SNF) days were 16% to 41% lower in MA, for instance.

In general, differences in post-acute care costs were similarly aligned with differences in utilization of post-acute care.

Across all populations, home health agency costs were about 38% lower in Medicare Advantage compared to FSS Medicare.

The Congressional Budget Office (CBO) forecasts that 47% of all Medicare enrollees will be Medicare Advantage beneficiaries by 2029.

“This study finds that overall Medicare Advantage delivered robust positive outcomes for high-need, high-cost beneficiaries compared to similar populations in traditional FFS Medicare,” the report continues. “Higher utilization of preventive screenings, preventive therapy and post-acute care follow-up in Medicare Advantage suggests that care management results in higher quality of care for this vulnerable population.” 

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‘Our Work Begins with Getting COVID Under Control’: What a Biden Administration Means for Home-Based Care

After one of the closest and most hotly contested campaigns in modern history, President-Elect Joe Biden addressed the nation on Saturday from an outdoor platform in Wilmington, Delaware.

While it’s far too early to say what the first 100 days of a Biden administration will look like from a detailed policy perspective, the president-elect has made one point abundantly clear. It’s time to get to work — and that work starts with the COVID-19 pandemic.

“Our work begins with getting COVID under control,” Biden said during his victory speech. “We cannot repair the economy, restore our vitality or relish life’s most precious moments — hugging a grandchild, birthdays, weddings, graduations, all the moments that matter most to us — until we get this virus under control.”

As the United States inches closer toward the macabre milestone of 10 million total coronavirus cases, the Biden administration’s response to the ongoing pandemic will need to be wide-ranging and thorough, touching on everything from vaccine development and distribution, to additional rounds of relief for health care providers. Long-term care and protecting America’s senior population will also need to be at the very center of its response.

“I will spare no effort — or commitment — to turn this pandemic around,” Biden continued.

In the weeks and months leading up to his victory this past weekend, Biden — a soon-to-be 78-year-old man himself — suggested a deep appreciation of home-based care.

In July, for example, the former vice president outlined a $775 billion plan to overhaul the nation’s caregiving infrastructure, which is mostly made up of women and people of color. As part of that plan, Biden said he hoped to create upwards of 3 million new caregiving and education jobs over the next decade, while likewise creating pathways for former caregivers to re-enter the workforce.

The plan additionally called for a $450 million boost for senior care, with some of those funds dedicated to improving wages and labor conditions for in-home care workers.

“Home health workers do God’s work, but aren’t paid much,” the then presidential candidate said on social media. “They have few benefits, and 40% are still on SNAP or Medicaid. It’s unacceptable. I’ll give caregivers and early childhood educators a much-needed raise.”

Biden hasn’t just highlighted his appreciation of home-based care in broad strokes and policy promises. In addition to his $775 billion plan, the president-elect has repeatedly brought attention to very specific, innovative programs that typically only industry insiders know about.

That includes making nuts-and-bolts references to CAPABLE, the increasingly popular program out of the Johns Hopkins School of Nursing designed to support aging in place by coordinating nursing, therapy and handyman services in the home.

“To hear him really describe [CAPABLE] was thrilling,” Sarah Szanton, the Johns Hopkins professor who helped create the program, recently told Home Health Care News.

Protecting America’s seniors

Moving forward, Biden and his staff will likely try to secure additional resources for home-based care providers and other long-term care operators. In its official policy plan for nursing home regulations, for instance, the Biden team stated it would invoke the Defense Production Act to increase the overall supply of PPE.

The campaign was highly critical of the Trump administration for failing to coordinate sufficient distribution of testing supplies and personal protective equipment (PPE) early on, so a lack of action on that front would only be viewed as hypocritical.

Currently, “protecting older Americans” is one of the main priorities featured on the Biden-Harris Transition website. That fact that hasn’t gone overlooked by those in the aging services space.

“We appreciate the Biden-Harris Transition team’s announcement regarding its COVID-19 response,” Argentum CEO James Balda said in a statement. “The specific emphasis on protecting at-risk populations, which includes older adults and those who serve them, as well as a focus on the efficacy of vaccine distribution, is critical to controlling the spread of this virus.”

Argentum is the country’s largest senior living association.

The Biden-Harris Transition team announced the formation of its 13-person Transition COVID-19 Advisory Board on Monday. The advisory board will be led by former FDA Commissioner Dr. David Kessler, former Surgeon General Dr. Vivek Murthy and Dr. Marcella Nunez-Smith, a Yale physician and researcher.

“Dealing with the coronavirus pandemic is one of the most important battles our administration will face, and I will be informed by science and by experts,” President-Elect Biden said Monday.

Notably, the advisory board also includes Dr. Atul Gawande, the surgeon and writer who founded Ariadne Labs, a joint center between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health.

Gawande — former CEO of Haven, the health care venture founded by Amazon, Berkshire Hathaway and JPMorgan Chase — has been a staunch supporter of palliative medicine and end-of-life care. His participation on the board could signal a focus on those areas during the duration of the public health emergency.

The Coalition to Transform Advanced Care (C-TAC) said it has been encouraged by a number of Biden campaign proposals that have the potential to improve the lives of the seriously ill, particularly in home- and community-based settings.

“C-TAC looks forward to forging new relationships with those in the incoming Biden administration and Congress,” C-TAC Executive Director Jon Broyles said in a statement. “As we work toward building a health care system that works for everyone, it is essential that we come together to find innovative solutions that meet the needs of the sickest and most vulnerable among us, with particular attention to low-income, traditionally underserved individuals.”

Beyond home care

The advisory board may include others in days to come.

Given the pandemic’s outsized impact on people age 65 and older, additional expertise in aging — whether via gerontologists, industry leaders or researchers — would bring much value, according to Ruth Katz, LeadingAge’s senior vice president of policy. LeadingAge is a diverse association of nonprofit providers of aging services.

“We expect to see a focus on in-home and community-based services through programs in their platform on caregiving, education and workforce,” Katz said in a statement. “That’s a positive.”

Beyond directly supporting home-based care, a Democratic president in the White House and a split Congress may also mean a heightened willingness to reach across the aisle to get things done, at least compared to the past four years.

Initially, there’s bound to be friction between both governing parties, a concept reflected in the largely unsubstantiated voter-fraud concerns voiced by Republican leadership. Over time, though, lawmakers will hopefully find common ground on no-brainer, common-sense issues.

That could mean newfound momentum behind legislation with bipartisan support, such as the Home Health Emergency Access to Telehealth (HEAT) Act, a bill to provide Medicare reimbursement for audio and video telehealth services delivered by home health agencies during a public emergency. Among the bill’s backers is Sen. Susan Collins of Maine, one of the few Republicans to officially congratulate Biden on his victory.

It could also mean continued support for Medicare Advantage (MA), which, in turn, means continued support for home care. Often cited as the future of health care by Republicans, MA was actually first enacted under the Clinton administration as “Medicare Plus Choice.”

Better Medicare Alliance President and CEO Allyson Y. Schwartz reminded people of that on Monday.

“The story of Medicare Advantage is one this new administration can be proud to continue,” Schwartz, a former member of the U.S. House of Representatives, said in a statement. “We stand ready to work with President-elect Biden, Vice President-elect Harris and their team to build on this bipartisan success.”

Out of a total Medicare-eligible population of more than 62.4 million individuals as of October 2020, nearly 25.4 million had signed up for MA, federal statistics show.

Biden, of course, has also voiced support for “Medicare at 60,” a plan to allow Americans between the ages of 60 and 64 the option of buying into Medicare slightly earlier. If ever enacted, that plan would dramatically expand the population of Medicare beneficiaries able to receive Medicare-certified home health services.

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Medicare Advantage Enrollment Up 125% Among Dual-Eligible Beneficiaries

In-home care providers with a mission to serve particularly vulnerable populations often target “dual eligibles,” or individuals signed up for both Medicare and Medicaid benefits.

The focus on dual-eligible populations is partly driven by mission and values, but it’s also supported by reimbursement. While in-home care providers sometimes struggle operating purely in the Medicaid long-term care space due to stagnating reimbursement rates, the dual-eligible landscape offers more financial sustainability.

Take, for example, Huntington Beach, California-based Landmark Health, a company that coordinates and delivers in-home medical care to mostly older adults with complex conditions.

Landmark currently operates across more than a dozen states, with dual-eligible beneficiaries being an important part of its overall patient mix of roughly 114,000.

CEO Nick Loporcaro discussed the strategic value of duals Thursday during the Better Medicare Alliance (BMA) Medicare Advantage Virtual Summit.

“If you look at the Medicaid population, due to what I call a flawed reimbursement system …, we have a tough time justifying the costs around that,” Loporcaro said. “Now, if I’ve got the MA advantage, I get to address and take care of a population that I would have struggled to justify bringing in. So, we actually like duals and perform well with duels.”

Specifically, Loporcaro was referring to dual-eligible beneficiaries enrolled under Medicare Advantage — a rapidly growing population.

Of the roughly 9.6 million full or partial dual-eligible individuals in 2013, about 2.4 million — or about 25% — enrolled in Medicare Advantage, according to a new report from actuarial consulting firm Milliman and BMA. By 2019 the number of total dual eligibles increased to 12.3 million individuals, with 5.4 million — or about 44% — enrolling in Medicare Advantage.

That’s a jump of about 125% over six years. From 2013 to 2019, the number of dual-eligible beneficiaries enrolled in traditional Medicare dropped by 5%.

Source: The Better Medicare Alliance

“[With] dramatic growth in enrollment among dual-eligible beneficiaries, we know that supporting health coverage for our most vulnerable seniors means supporting these individuals’ choice of Medicare Advantage,” BMA President and CEO Allyson Y. Schwartz said in a press release touting the report.

Dual-eligible individuals typically have more social determinants of health needs, possibly one reason for the increase under Medicare Advantage, especially as more plans offer home-focused supplemental benefits.

Medicare Advantage growth

The sharp rise in dual eligibles in Medicare Advantage is an important consideration for in-home care providers attempting to move away from fee-for-service Medicare.

Of course, it’s not just the duals population that is increasing, as overall Medicare Advantage continues to climb as well, the BMA-Milliman report shows.

In 2019, there were about 64 million Medicare beneficiaries in total, with roughly 24 million — or more than 37% — enrolling in a Medicare Advantage plan. The Congressional Budget Office (CBO) projects that Medicare Advantage enrollment will grow to nearly 50% by 2029.

Source: The Better Medicare Alliance

Former CMS Administrator Tom Scully — who helped create the Medicare+Choice model, a precursor to today’s Medicare Advantage program — touched on that growth during BMA’s virtual summit.

“I’m very bullish on the future of Medicare Advantage. I think it’s a great program,” Scully said. “The growth is going to continue, and that’s because seniors like it, seniors support it and, economically, it makes a whole lot of sense.”

While the Medicare Advantage population grew by 60% from 2013 to 2019, the fee-for-service Medicare population only grew by 5%.

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‘There’s No Undoing This Revolution’: HHS Secretary Alex Azar Touts In-Home Care, Virtual Visits

U.S. Department of Health and Human Services (HHS) Secretary Alex Azar believes that COVID-19 has led to a health care revolution, one that will include a larger focus on care in the home.

Specifically, Azar thinks the increase in telehealth usage and a stronger focus on social determinants of health will be major influences in a more value-based health care system in the U.S moving forward.

“One of the instructive experiences from COVID-19 has been the vastly expanded role of telehealth,” Azar said Thursday at the Medicare Advantage Virtual Summit, hosted by the Better Medicare Alliance. “We went from about 14,000 virtual visits in Medicare fee-for-service each week before the pandemic to nearly 1.7 million virtual visits a week, at the peak. There’s no undoing this revolution.”

Although the ongoing public health emergency has increased the need for home-based care, the federal government has recognized the crucial part it plays in the health care system for years. That recognition is partly reflected by the evolution of Medicare Advantage (MA), Azar said.

“We’ve already worked over the past several years to create permanent flexibilities … in Medicare Advantage, expanding the ability for plans to pay for virtual check-ins and a wider variety of circumstances, allowing patients to receive this care from the convenience of their home rather than a doctor’s office,” the HHS secretary added.

Additionally, through the changes that have occurred to telehealth during the COVID-19 crisis, rural residents will begin experiencing easier access to care, Azar said.

Rural access to care has long been an inequity of the U.S health care system.

The COVID-19 pandemic has also exposed the disparities in care for both underprivileged and chronically ill populations. The expanded MA benefits — both the primarily health-related ones and those under the new Special Supplemental Benefits for the Chronically Ill (SSBCI) program — are a way to address those disparities moving forward, Azar believes.

“We want to support you in addressing these disparities and health challenges in a holistic way,” he said. “And that has informed our efforts to expand the array of supplemental benefits that MA plans can offer.”

Last month, the U.S. Centers for Medicare & Medicaid (CMS) released new data in a 2021 MA preview. It revealed that 738 plans are offering primarily health-related supplemental benefits in 2021, a 46% increase compared to the nearly 500 plans that did so in 2020.

It also showed that 920 plans are offering benefits under SSBCI pathway next year, a nearly 400% increase compared to the 245 plans that did so this year.

“All of you have made it a priority to address social determinants of health,” Azar said. “And that is an area of great interest for us as well. Addressing costly and debilitating chronic conditions can sometimes be impossible without addressing particular non-health needs. And MA allows you to do that in a way that focuses on value outcomes and a patient’s individual needs.”

Zeroing in on social determinants will be easier with more MA plans carrying SSBCI benefits in 2021 and beyond.

In general, the pool of MA beneficiaries is also getting larger, which will help providers reach and care for more individuals.

The actuarial firm Milliman recently examined growth in MA enrollment over recent years; the firm’s results showed an increase of 60% in MA enrollment from 2013 to 2019. Enrollment among beneficiaries in traditional Medicare only increased 5% during the same time frame. 

“This independent report offers an eye-opening look at Medicare Advantage’s explosive growth,” Allyson Schwartz, the president and CEO of the Better Medicare Alliance, said in a press release. “And with dramatic growth in enrollment among dual-eligible beneficiaries, we know that supporting health coverage for our most vulnerable seniors means supporting these individuals’ choice of Medicare Advantage.”

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