Health Innovation Highlights: August 7, 2019

Full Edition

DIRECTORS CORNER

Medicare and Medicaid at 54: Consumer Stories and Changes Ahead

Ann Hwang, MD
Director, Center for Consumer Engagement in Health Innovation

As Medicare and Medicaid turn 54, these two programs are more important than ever for the health and well-being of millions of Americans. This month, I’m grateful to share a number of new stories and photos on our website from people around the country illustrating just how critical these public programs are to all of us. Courtesy of our partners Alabama Arise, Colorado Consumer Health Initiative and Idaho Voices for Children, you’ll meet a number of people who share how important it is to have health care that meets their unique needs and the needs of their families. Please take a minute to view our story gallery here. And if you know an amazing consumer champion who is working to improve their health and the health of their communities, please remember to nominate them for our Speak Up for Better Health award! Nominations are due Sept. 6.

In their second half-century, Medicare and Medicaid continue to evolve and change. Center Strategic Policy Manager Danielle Garrett and Research Director Marc Cohen recently participated in a collaborative effort to define how Medicare health plans should deliver services that go beyond traditional health care services in order to address beneficiaries’ social needs and other factors that affect their health, while preserving important beneficiary protections. Learn more about this work here.

Even as Medicare and Medicaid continue their vital roles in providing care to low-income people and families, people with disabilities and older adults, we are constantly reminded of the continued threats to these programs. This month, we’re honored to feature an Eldercare Voices column from Katie Smith Sloan, President and CEO of LeadingAge, a national organization of over 6,000 members and partners, including not-for profit organizations, representing the entire field of aging services. This column discusses recently proposed changes to how the federal government would calculate the poverty threshold, making it harder for older adults to qualify for programs like Medicaid and, over time, depriving millions of people of services they need. This is a topic that Community Catalyst is continuing to highlight, and you can read more about the threat here.

And finally, I want to acknowledge the horror and heartbreak of the shootings in El Paso and Dayton over the weekend, and in Gilroy last month. In this time of sorrow, anger, fear and loss, I hope we will continue to be a supportive and caring community for each other, and, in the words of UnidosUS President Janice Murguia, “to rise above fear, division and hate and restore respect, dignity and common humanity for all.”

FROM THE CENTER & OUR PARTNERS

Deadline for the Center's 2nd Annual Speak Up for Better Health Award Nominations: September 6!

It’s been a little over a month since the Center announced our second annual Speak Up for Better Health award. This year’s award will recognize people who are working to address the social, environmental and economic factors – e.g. housing, transportation or nutrition – that play a crucial role in our health.. We’ve already received a number of nominations, but we know there are many more unsung heroes out there!

If you know a consumer champion who deserves recognition and celebration, please nominate them! Entries are open until Sept. 6 and they could win $500 and a trip to our November award ceremony in Washington, D.C.

Community Catalyst is Hiring: Program Director, Consumer and Community Engagement

Community Catalyst is looking for an experienced, consumer-driven leader to join its team! The Consumer and Community Engagement Program is a new national program that supports community-based organizations to build power to improve health care delivery and address equity. The program is designed to pair funding resources for community organizations with a robust technical assistance program to equip consumer and community organizations with the resources, strategies and partnerships needed to foster respectful relationships between consumers and local health systems based on honesty and a commitment to equitable, positive care for consumers.

The program director is a senior level position that provides leadership, strategic direction and overall management for the Consumer and Community Engagement program. It will be critical for the director to shape and implement their vision for a program that supports outreach and participation by community-based organizations, particularly those serving communities of color and other diverse communities. Click here to learn more and for information about how to apply.

Center Staff Help Develop Guiding Principles for MA Plan Special Supplemental Benefits

People with complex care needs often require non-medical services and supports to complete many daily activities – things like transportation to adult day care centers, retrofitting a home for wheelchair use and support for caregivers, among others. Starting in January 2020, these benefits – grouped together as Special Supplemental Benefits for the Chronically Ill (SSBCI) – can be covered by Medicare Advantage (MA) plans to help meet individual needs and save chronically ill older adults and people with disabilities out-of-pocket costs. This is an exciting opportunity to improve care for older adults, but it will be important to ensure plans are implementing the benefits in a consumer focused way. To this end, Center Strategic Policy Manager Danielle Garrett and Research Director Marc Cohen have spent the last serval months working with a group of multi-sector stakeholders, convened by the SCAN foundation, to develop a set of guiding principles for CMS and Medicare Advantage plans to use in creating and implementing these new benefits. These SSBCI guiding principles include:

  • Providing clear, explicit and understandable benefits information to consumer and family caregivers
  • Ensuring equitable and consistent service provision that is based on consumer need and functionality
  • Ensuring that SSBCI are manageable and sustainable by aligning guidance, rate structures, and quality measures with those of Medicare
  • Creating built in evolutionary mechanisms to allow for continuous learning and improvement of systems and delivery

Click here to learn more about the benefits themselves and the implementation principles the Center supports.

Toolkit: Coverage Options for Dually Eligible New Yorkers

Center partner the Medicare Rights Center has begun its rollout of a toolkit for consumers and consumer advocates breaking down Coverage Options for Dually Eligible New Yorkers. The toolkit currently includes a definitions glossary, information about Medicaid Advantage Plus enrollment and a guide to help currently enrolled Fully Integrated Duals Advantage (FIDA) members transition to other plans when the FIDA demonstration ends on Dec. 31. Additional resources, including information regarding Dual Eligible Special Needs Plans and Medicaid Advantage and a guide to decision-making for special populations, will be rolling out in 2019-2020. Keep an eye out for tools as they become available.

Watchdog Report: Non-profit Hospital Methodist Le Bonheur Healthcare in the Spotlight After Abusive Collections Policies and Practices Exposed

In a series entitled “Profiting From the Poor,” ProPublica and MLK50 exposed disturbing and aggressive tactics non-profit hospitals are engaging in to squeeze high payments from low-income patients, including their own employees. One hospital in particular – Methodist Le Bonheur Healthcare (Methodist) – was spotlighted for its more than 8,000 lawsuits filed against low-income patients in the Memphis area, where about one in four residents live in poverty, drawing attention to the in-house collections agency the hospital uses to enforce its medical debt collections practices. The series prompted Methodist to announce that it would review its policies to ensure more fair and equitable practices going forward. Center Senior Advisor Jessica Curtis, who leads the Center’s work on hospital community benefits, along with Mark Rukavina, the Center’s Business Development Manager, responded by publishing a set of recommendations for Methodist to consider as it reviews its policies including:

  • Engaging consumers who have been subjected to their collections tactics, including its employees, to determine where patients could have utilized more or better assistance from the hospital
  • Basing eligibility for financial assistance on need, not coverage status
  • Adopting collections policies that do not sink low-income patients into more debt
  • Ceasing garnishing wages of those patients with high bills
  • Ensuring that employees in charge of patient care and billing have the tools to help patients apply for assistance and work with community organizations to get the word out about financial assistance programs

Late last month, Methodist announced it would raise the minimum wages paid to employees to help safeguard its workers from collections dilemmas and will stop suing its own employees for unpaid medical debt. Additionally, the hospital says it will expand its financial assistance programs. Methodist CEO and President Michael Ugwueke told reporters, “We were humbled to learn that while there’s so much good happening across our health system each day, we can and must do more.” Many questions remain about how the hospital will proceed, and as of this writing it has not completely suspended its collections lawsuits against patients. Community Catalyst will be monitoring its progress as the story develops.

Upcoming Webinar: Self-Direction for Dually Eligible Individuals Utilizing LTSS

On Aug. 21, the Center will present a webinar in collaboration with the Medicare-Medicaid Coordination Office and The Lewin Group, “Self-Direction for Dually Eligible Individuals Utilizing LTSS.” Self-direction, often referred to as consumer-direction, is a practice that allows consumers to direct and manage their own personal care services. It is based on the premise that individuals receiving long-term services and supports (LTSS) know their needs best. This webinar will discuss the importance of care coordinators, person-centered care planning and assisting members with management tasks required for self-direction for plans seeking to support consumers in directing their own care. The webinar is scheduled for Wednesday, Aug. 21 - 12:00 to 1:30 p.m. EST. Click here for more information and to register.

NOTEWORTHY NEWS & RESOURCES

X-Rays Meet the ADA: Making the Case for Accessible Health Care

A new blog post from the Administration for Community Living (ACL) lays out the progress made as a result of the Americans with Disabilities Act (ADA), but draws attention to widespread disparities in access to vital health care diagnostic equipment for people with disabilities. The blog links to a new issue brief and business case study from the ACL, “Wheelchair-Accessible Medical Diagnostic Equipment: Cutting Edge Technology, Cost-Effective for Health Care Providers, and Consumer-Friendly,” that goes into detail on the importance of clinical provider sites having the infrastructure to accommodate people with disabilities. At this point in time, compliance with a set of voluntary standards issued in 2017 by the U.S. Access Board for accessible medical diagnostic equipment has not been widely adopted by providers. The ACL case study makes a business-oriented argument for why health providers should move quickly to meet these standards and upgrade their care to equitably treat people with disabilities.

Study: Home-Delivered Meals Can Improve Outcomes for Older Adults and Save Money for Medicare

A New York Times article on a new study by the Bipartisan Policy Center (BPC) shows that Medicare spending on healthy, home-delivered meals could help some older adults avoid repeat hospital stays. While supplemental services like meal delivery are available in some Medicare Advantage plans, they have yet to be included in traditional Medicare. The BPC study found, “Medicare could save $1.57 for every dollar spent delivering free healthy meals to frail seniors after a hospitalization.”

CMS Releases Three New ACO Case Studies

CMS has released three new case studies on innovative programs in Medicare ACOs, each featuring a new initiative. The first highlights staff development through leadership academies, which are monthly discussion-oriented meetings that aim to increase collaboration among staff. The second describes a home visit program meant to improve the care experience and health outcomes of beneficiaries. The third describes efforts to engage providers in developing the structure for an ACO's governance. (Case studies available at the bottom of this webpage.)

New Primer on D-SNP “Look-Alikes”

Justice in Aging (JIA) has released a new primer that identifies basic features of Dual Eligible Special Needs Plans (D-SNPs) and highlights problems with so-called “look-alike” plans. These look-alikes are Medicare Advantage plans marketed to dual eligible individuals that are not actually D-SNPs or integrated products. These look-alike plans have almost doubled in number since 2017 and are now available in 35 states.

JIA explains: “They [look-alike plans] are not subject to the regulations governing D-SNPs and have no responsibility to coordinate Medicare and Medicaid benefits. Unlike D-SNPs, they have no contracts with state Medicaid agencies that define their responsibilities to better integrate care for duals and no accountability. They draw dual eligibles away from coordinated options and place responsibility on the consumer to navigate two separate delivery systems.”

ELDERCARE VOICES

Changing the Way the Poverty Level is Calculated Will Harm Older Adults

Katie Smith Sloan  

In May, the White House Office for Management and Budget (OMB) published a request for comment on potential changes to how the federal government measures poverty. On June 20, LeadingAge, along with other aging advocates, commented on the serious impacts these potential changes would have on older adults and on aging services.

In short, if the federal government were to proceed on certain proposals discussed in the request for comment, fewer older adults would be eligible for publicly-funded aging services over time and, consequently, aging services providers would be unable to serve huge numbers of low-income older adults who very much need such supports.

Frankly, I’ve had enough. Since being introduced to the field of aging services early in my career while working on Capitol Hill in Sen. Thomas Eagleton’s office, I’ve heard far too many stories about older adults facing unconscionable choices about basic human needs. No one should have to choose between paying for vitally needed prescription medicine or their rent; having nutritious food or shoes on their feet. As a nation, we can – and must – do better.

Each year, the U.S. Census Bureau establishes the poverty threshold, or the income level under which individuals and families are considered to be living in poverty. In 2018, the poverty threshold for a single adult age 65+ was $13,064.

The poverty threshold is used to determine the federal poverty level (FPL), which is then used to determine eligibility for a wide range of programs important to older adults and aging services providers, including Medicaid long-term services and supports (LTSS), nutrition benefits, Medicare subsidies and more. In short, these services are a lifeline for people who can’t otherwise afford the basic necessities they need to live, let alone thrive.

The U.S. Census Bureau increases the poverty threshold each year to keep pace with inflation. Historically, it has used the consumer price index for urban consumers (CPI-U; colloquially known as the “consumer price index”) to do so. In the request for comment, OMB lists other potential inflation measures that could be used instead of the consumer price index, including an alternative “chained” CPI-U.

If the federal government were to adopt this chained CPI-U as the inflation factor for increasing the poverty threshold, the immediate impact would be fewer people considered to be living in poverty compared to continued use of the current methodology. And over time, ever fewer people – including older adults – would have access to vital services that use the FPL as the determinative eligibility criterion.

Changes to the poverty threshold calculation would have specific and negative implications for access to LTSS and other aging services. According to the Medicaid and CHIP Payment and Access Commission, every state uses the FPL to determine eligibility for Medicaid LTSS both in nursing homes and in home and community-based settings. While states use varying percentages of the federal FPL as eligibility criteria for certain state programs, there is consistent use nationally of FPL as the financial eligibility determinant for Medicaid LTSS. The proposed changes in calculating the poverty threshold would establish a downward spiral over time in the numbers of older adults who would otherwise have met the eligibility standard.

To sum it up: Older adults with low incomes would be at even greater risk without access to the LTSS they need, and aging services providers of all types, including nursing homes, home-based care providers, adult day services centers, PACE organizations and more, would be restricted to serving fewer people through Medicaid.

Why does this news keep me up at night? Because 10,000 people are turning 65 every day and will continue at that pace until 2030. In other words, 40 million people 65 and older in the U.S. by 2030.

I often think about the implications of these numbers as we assess the impact on programs that support older adults, particularly those without the resources to meet their health and wellness needs. This reality is sobering as we know that slightly more than half of people over the age of 65 will at some point need help with everyday activities, which aren’t covered by Medicare.

To further complicate matters, there is a dire shortage of affordable housing with services for seniors. Waiting lists are already years-long in many places and homelessness among this population is growing exponentially. Older adults pay a small percentage of their income to have access to an affordable apartment, but when one’s income is $13,064 or less, every dollar counts.

Adjusting the poverty threshold means less money in older adults’ pockets and the imposition of more unconscionable choices. And that just isn’t okay. Let’s support regulations that lift people up, not keep them down.

Katie Smith Sloan is president and CEO of LeadingAge, a national organization of 6,000-plus members and partners that include not-for-profit organizations representing the entire field of aging services, 38 state partners, hundreds of businesses, consumer groups, foundations and research partners. LeadingAge is also a part of the Global Ageing Network (formerly IAHSA), which spans 30 countries across the globe.

STATE HIGHLIGHTS

Maryland

The Baltimore Fishbowl reports that ten hospitals are pooling funds together (totaling $2 million) toward a program that provides housing and medical services for people experiencing homelessness. A part of these funds will also be used to remove barriers to housing such as security deposits, furniture, application fees and transportation. Participating hospitals receive matching funds from Medicaid through the Assistance in Community Integration Services Pilot administered by the Maryland Department of Health. One of goals of the program is to show that homeless individuals who receive treatment in permanent housing will ultimately see a reduction in health care costs. In addition to hospitals pooling funds, an additional $200,000 is coming from The Weinberg Foundation.

New York

The New York Department of Health posted the phase-out plan for the Fully Integrated Dual Advantage (FIDA) program the state’s dual eligible demonstration project that began in 2014 and is (?) set to end on Dec. 31. . According to the phase-out plan, all FIDA enrollees will be transitioned to the Medicaid Advantage Plus plan affiliated with their current FIDA plan, unless they choose a different option.

In other news, the United Hospital Fund has released a report that examines New York’s Delivery System Reform Incentive Payment (DSRIP) program. The report reviews Performing Provider System (PPS) projects to assess common themes across the projects, and identify key lessons. The report highlights five key take-aways:

  1. Substantial infrastructure is required to support projects with sufficient scope to drive outcome improvement across large populations of Medicaid members attributed to individual PPSs
  2. Projects targeting complex patients can significantly improve outcomes for small groups of patients (and likely generate cost savings)
  3. DSRIP has greatly accelerated the focus on social determinants of health by facilitating partnerships between health care providers, community-based social service organizations and other community partners
  4. For the most complex populations, substantial care management/coordination and support for care transitions appear necessary to change patients’ trajectories
  5. Given the prevalence of individuals in Medicaid with behavioral health needs, the heterogeneity of those needs, and this population’s relatively high utilization and costs, some of the most promising practices focused on expanding access and developing new approaches to meeting patients where they are as ways to better engage them in treatment

The DSRIP waiver ends on March 31, 2020; the state is in the process of developing a waiver extension request to CMS.

Oregon

The Oregon Health Authority announced the awards for the Oregon Health Plan CCO 2.0 Medicaid program for the 2020 contract year. A total of 15 coordinated care organizations (CCOs) were awarded contracts – 11 CCOs for five-year contracts and four for one-year contracts.

KEY DATES 

Thursday, Aug. 8 (1:00-2:00 p.m. Eastern) - Webinar: Bridging the Gap – Successful Health and Community Development Partnerships in Practice, presented by Build Healthy Places Network and NeighborWorks America. Please register for the webinar.

Wednesday, Aug. 21 (12-1:30 p.m. Eastern) - Webinar: Self-Direction for Dually Eligible Individuals Utilizing LTSS, presented by The Lewin Group and the Medicare-Medicaid Coordination Office in collaboration with the Center for Consumer Engagement in Health Innovation. Please register for the webinar.

Wednesday, Aug. 21 (2-3 p.m. Eastern) - Webinar: Accessing Behavioral Health Services for Older Adults, presented by the National Center on Law & Elder Rights. Please register for the webinar.

Thursday, Sept. 5 (2-2:30 p.m. Eastern) - Live Event: Disability-Competent Care Conversation on Care-Coordination with ICS, presented by The Lewin Group and the Medicare-Medicaid Coordination Office. Please register for the event.