WHY MEDICARE’S FOCUS IS CHANGING TO CHRONIC CONDITIONS
By RON STOCK
“It ain’t your father’s or grandfather’s Medicare.” After 48 years Medicare is changing its health care focus from treatment of acute diseases to caring for Medicare beneficiaries with chronic diseases. Why?Simple! Eighty-six percent of the nation’s $2.7 trillion annual health care expenditures are for people with chronic and mental health conditions. About 65 percent of Medicare beneficiaries have two or more chronic diseases, and 43 percent have three or more. Reducing chronic expenses is the fastest way to bring the exploding Medicare costs under control.
Chronic diseases are often caused by unhealthy behaviors that increase the risk of disease—poor nutrition, inadequate physical activity, overuse of alcohol or smoking. Social, emotional, environmental and genetic factors also play a role. As people age, they are more likely to develop one or more chronic disease.
How ill is America’s health? The picture isn’t pretty:
• During 2011–2014, more than one-third of adults (36 percent), were obese.
• 36.5 million adults in the United States (15.1 percent) said they currently smoked cigarettes in 2015.
Cigarette smoking accounts for more than 480,000 deaths each year.
• 90 percent of Americans aged two years or older consume too much sodium, which can increase their risk of high blood pressure. Of course, obesity, smoking-related disease and high blood pressure are key chronic diseases. Chronic diseases are painful diseases; example quotes of chronic patients taken from an online site:
• “Sitting down in the shower to shave because it’s easier on my joints. I sometimes forget that many
people stand to shave.”
• “I have a habit of collecting my hospital bracelets after I get out of the hospital as it reminds me that I won yet another battle. It seems odd, but for some reason, I hold onto the bracelet feeling empowered that I walked away from what tried to defeat me again.”
SELLING C-SNP MEDICARE ADVANTAGE PLANS
You better get to know how to present C-SNP plans as ‘chronic’ is the new buzzword with Medicare. The Center for Medicare and Medicaid Services (CMS) has opened the door for health plans to add Value-Based Insurance Design (VBID) benefits such as air conditioners for asthma patients, home health benefits, healthy groceries, home-delivered meals and installing safety items like grab bars.
As an example of a health plan’s preparation for the expansion of VBID, Humana recently purchased Kindred Healthcare. Kindred Healthcare owns an array of businesses including home health, hospice, long term care hospitals and inpatient rehabilitation facilities. Humana has a significant business administering Medicare health benefits for the elderly, and the Kindred deal helps Humana form closer ties with a provider of home care and related services predominantly used by the elderly.
Starting in 2019, health plans in California and other targeted states can expand their benefits to include more Medicare beneficiaries with chronic conditions than previously identified by CMS, such as diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and combinations of these categories. The new chronic list will include beneficiaries with lower back pain, chronic kidney disease, obesity/pre-diabetes, asthma, and tobacco use. Beginning in 2018, CMS also allowed benefits for enrollees with dementia and rheumatoid arthritis. Medicare Advantage plans can cover adult day care services, and in-home help with activities such as dressing, bathing and managing medications. Seema Verma, the administrator CMS, told insurance company executives at a recent conference that “CMS hopes its new ‘reinterpretation’ of the Medicare Advantage program benefits rules will help unleash private-sector innovation and creativity.”
CMS further states, “Plans adding benefits based on the supplemental benefits interpretation must make sure the benefits are ‘primarily health related,’ and not primarily for a patient’s comfort. The services covered must be recommended by a physician or other licensed medical professional as part of a care plan.
The new benefits must not include items or services used to induce enrollment. “The primary contributor to the shift in focus to chronic diseases is Congress passing “The Chronic Care Act of 2018,” February 9, 2018, which opened the doors to the inevitable expansion of C-SNP or “Look-Alike” C-SNP Medicare Advantage Plans that provide VBID benefits. Two of the main sections of the bill that impacts health plans and the brokers that sell them are:
1. Allows MA plans to offer an expanded set of supplemental benefits to the chronically ill enrollee. Enables MA plans to experiment with different types of benefit packages to meet the needs of chronically
2. Permanently authorizes three types of SNPs: D-SNP (dual eligibles), C-SNP (those with severe disabling chronic conditions), and I-SNP (those in institutions). C-SNPs must meet additional care management requirements starting in 2020. By 2022, and every five years after that, the Health and Human Services (HHS) Secretary must update the list of chronic conditions eligible for participation. The list must include HIV/AIDS, end-stage renal disease and chronic/disabling mental illness.
CDC AND THE STATE OF CALIFORNIA
The Centers for Disease Control and Prevention (CDC) established a comprehensive chronic disease program.The four major components are:
1. Implemented systems that track chronic diseases and their risk factors.
2. Promotes health and support healthy behaviors across the nation, in states and communities, and in settings such as schools, child care programs, work sites and businesses.
3. Developed programs and policies that allow doctors to diagnose chronic diseases earlier and manage them better.
4. Established community programs linked to clinical services to help patients prevent and manage their chronic diseases, with guidance from their doctor. The State of California Chronic Programs, http://www.cahealthierliving.org/programs/, includes services for health self-management, fall prevention and physical activity, and caregiver and memory programs. The VBID benefits cannot cure chronic diseases but can aid in reducing the hospitalizations due to chronic illnesses. CDC recommends six healthy aging suggestions (as seen by the graph on this page).
The New Medicare and You has a chronic condition focus. You can count on the majority of your Medicare
clients having one or more chronic diseases and they would probably like to to hear about the VBID benefits
of a C-SNP or an MA plan with VBID benefits. Already, there are MA and C-SNP health plans with added benefits, such as:
• Health Coach
• Care Management
• OTC Supplies
• Lower Cost Travel Tiered Copays
• Gym Membership
• Quit Smoking Programs
• Nutritional Programs
The emphasis on chronic and CSNP plans also creates a yearlong enrollment opportunity for brokers. Eligible Medicare beneficiaries can enroll anytime during the year into a C-SNP plan with their PCP’s confirmation of their chronic illness. ‘Lockin’–where you can only enroll new to Medicare beneficiaries – is becoming antiquated given C-SNPs. With the new OEP now January 1 to March 31 and AEP October 15 to December 7 and C-SNP’s and New-to-Medicare, enrollments are now a full-time enrollment opportunity. Oh, not forgetting D-SNPs for Dual Eligibles and I-SNPs for Institutional members, brokers have unlimited enrollment opportunities.
THE ‘NEW MEDICARE AND YOU’
The ‘New Medicare and You’ is BetaBenefits’ title for our Medicare educational classes in which we discuss Medicare’s milestones (see chart) and the benefits each milestone provides Medicare beneficiaries. With CMS’ emphasis on chronic diseases and VBID benefits, shouldn’t you rethink how you present Medicare to your clients?