Today, one-third of the 19 million Medicare beneficiaries need help with at least one activities of daily living (ADL) or instrumental ADL due to a chronic condition. To meet the needs of an aging population, the Centers for Medicare & Medicaid Services (CMS) recently broadened its scope of Medicare Advantage plan benefits for 2019 to include nonclinical home care services. Private health insurance companies that take advantage of the policy change can improve the quality of life of their members, reduce long-term costs, and attract new members seeking these desirable benefits.

The Road to CMS Changes for Medicare Advantage Plans

Short-term medical benefits covered. Traditional Medicare Advantage plans, or “Part C” plans, have long covered skilled nursing or other medical home-care benefits delivered in seniors’ homes by a skilled or medical health agency. The benefits are usually short-term and covered only until the patient is able to get back on their feet.

Long-term non-medical benefits not covered. Many senior patients, however, need long-term non-medical supports due to existing medical conditions, transportation constraints, limited mobility, social isolation, chronic illnesses like end-stage renal disease, or cognitive issues such as Alzheimer’s disease.

Heavy individual and family costs. The burden of providing and paying for long-term care typically rests on seniors and their family members – expensive for them financially, physically and emotionally. Patients who are left to care for themselves without family or other supports particularly suffer, as they are at a higher risk for acute health events that lead to preventable emergency room visits and re-hospitalization.

Reasonable expectation standard. CMS’s step in treating chronic illnesses on a more holistic scale by allowing Medicare Advantage plans to offer new non-medical home-care supplemental benefits to seniors in 2019 is a bold and uplifting one. If plans believe their members “have a reasonable expectation of improving or maintaining the health or overall function” of their seniors, they can offer them long-term non-medical home-care benefits such as personal care, transportation and housekeeping. Plans can now address activities of daily living and social determinants of health like never before.

CMS goals. CMS’s key goals are to provide general care services that allow seniors to age in place for a higher quality of life and deliver patient oversight and monitoring to prevent health issues from reoccurring, escalating or happening altogether.

Home Care Defined

With CMS’s recent changes, Medicare Advantage plans can now offer non-medical care to assist seniors with activities of daily living, even if they’ve recovered from an acute setback. With more than 7 million Americans requiring personal care services and home care, the new Medicare benefits can be life-changing for this population, and in some cases, even life-saving. Examples of covered services may now include:

  • Assistance with bathing, dressing and grooming
  • Help with basic hygiene and toileting
  • Basic health management, such as overseeing a patient’s adherence to medication
  • Meal preparation and delivery
  • Light housekeeping
  • Transportation to and from medical appointments, therapy, adult day care, or other appointments
  • Assistance with a doctor-approved exercise program
  • General companionship
  • Respite care for families

More seniors may soon have access to these supplemental benefits, just as they do with Medicare prescription drug coverage, palliative care and hospice care – if Medicare Advantage plans decide to offer them to their Medicare Advantage members.

Benefits of Home Care to Medicare Advantage Plan Providers

The aging of America has placed a significant demand on health insurance providers, with over 20 million seniors choosing a private Medicare Advantage program. Fortunately, home care companies provide health plans with preventive and wellness services that rein in costs without cutting benefits for members. Some of outcomes of these services include:

  • Fewer readmissions and rehospitalizations. Every time a senior is admitted or readmitted to the hospital, both their financial health and that of their plan provider takes a hit. Of the 18 million Medicare members who are discharged from the hospital each year, 20 percent will end up back in the hospital within a month. Each year, Medicare spends $17 billion on readmissions, that according to the National Center for Senior House & Care (NIC) are classified as “potentially avoidable.” That’s a lot of savings on one element of healthcare alone.
  • Avoided hospitalizations and acute events. Personal care aides can serve as an extension of the patient’s medical care team, keeping providers informed of health changes and assisting with everyday tasks that can improve health and keep seniors out of the emergency room. Consider the following facts:
    • Ten percent of hospital admissions among the elderly are due to adverse drug reactions. A home care aide can help the patient understand complex medication plans and ensure they’re adhering to them, preventing the risk of a missed dosage or an overdose.
    • Regular doctor-approved physical activity can help lower one’s blood pressure, add an extra level of protection against heart disease and diabetes, and maintain healthy bones and joints. A home care aide can help members take a daily walk or drive them to a local gym for senior exercise classes.
    • By assisting seniors with bathing, personal hygiene and toileting, home care aides can significantly reduce one of the greatest threats to a senior’s overall health – falls in the bathroom.
  • Improved customer satisfaction. When a patient is healthier, happier and still at home thanks to cost-effective, plan-covered home care, their satisfaction with their Medicare Advantage plan can dramatically improve. Moreover, because an integrated approach to patient care can save them up to 30 percent in their expenditures over the year, the satisfaction seniors feel with greater financial health can assist with member retainment. All of this equates to higher star metrics, helping a plan stand out in the Medicare marketplace during open enrollment.
  • A competitive edge over other plans. Fifty-seven percent of Medicare patients want to see in-home care as part of Medicare Advantage plans moving forward. As potential members begin to search for a Medicare Advantage plan through Medicare.gov, the quality and performance of a plan’s home care benefits will be a selling point. Only 3 percent of Medicare Advantage plans currently offer in-home care services, giving those who build them into their plans over the next year a head start on their competition.
  • Lower costs. According to the AARP, 52 percent of Americans age 65 or older will need long-term care services at some time in their golden years, with more than 1.4 million of them living in an assisted living or receiving nursing home care at any given time. Skilled care facilities come at a high cost; the national median is $253 per day, or $92,345 per year. Not only do seniors tend to be happier in their own homes, but it saves money as well.

What Medicare Advantage Plans Should Look For in a Home Care Partner

The sudden shift toward preventative care from the CMS has left Medical Advantage program providers scrambling to find home care companies that possess the networks and technology they desire for their members. With a variety of partners to choose from, it’s important to analyze what they provide and how they provide it, keeping a close eye on five essential criteria:

A robust, background-checked caregiver base. A reputable home-care company should properly vet every professional caregiver to assist with member safety, from running comprehensive background checks to verifying certifications. Furthermore, the right partner will ideally offer continual training for staff, whether in person or through a learning platform.

Adequate compensation. Because the average yearly salary for a personal care aide is under $25,000, those agencies that pay on the higher end of the scale may be able to offer better patient care via an empowered, motivated and loyal workforce.

Coordinated care through real-time data. An excellent way to maximize patient outcomes is early intervention. A home care aide can serve as the eyes, ears and arms of a patient’s care team by via prevention activities and medical alerts. Cutting-edge agencies provide digital platforms that allow personal care aides to follow up-to-the-minute care plans online and input medical information to a digital dashboard so that providers can intervene before minor issues escalate into major ones.

Quality assurance. To reduce caregiver fraud and get the highest return on your investment, you want to ensure personal care aides deliver optimal care during the hours they are with your plan member. Good home care partners have quality processes in place to guarantee care is delivered as promised as demonstrated by phone check-ins, status calls with patients and families, and digital visit verifications.

Geographic reach. Plans need a caregiver network that can adequately serve their membership. While a state-licensed agency may have a team of highly experienced team members, guaranteeing continual coverage can be difficult. One option to consider is a platform-based professional caregiver marketplace that CNAs and home care aides can join from anywhere in the country and are then vetted by a care team. A digital platform adds an extra level of efficiency and continuity if for plans covering a multi-state region.

Data and statistics to back up their work. Because the CMS rulings have altered how ADL home care is reimbursed, many home care agencies are playing catch-up to ensure they offer the services Medicare Advantage plans and their members need.

In interviews with some of the largest private insurance providers in the country, Home Health Care News found that the main requirements for home care companies are “to have the systems and processes in place to integrate with the larger health care ecosystem, to be able to flag issues and drive more targeted interventions to keep beneficiaries healthy and costs down.” Those personal care providers that have these in place and the data and statistics to demonstrate their viability have an immediate advantage over those who don’t.

Additional Home Care Advantages for Medicare Advantage Plans & Beneficiaries

If a senior’s chronic illness, disability or other limitation weakens their ability to perform necessary daily tasks, they eventually will need help in either an assisted living or skilled nursing facility or at home. Which one’s less expensive from both a health and financial perspective? Help provided in the senior’s home.

A home care aide can help seniors hold on to their independence a little longer by helping them with ADL and personal care needs—and in many cases, help prevent unexpected health setbacks. Just as important, home care helps preserve dignity, something many seniors feel they lose as they grow older and frailer. Additional advantages of offering home care to MA members:

  • Faster recovery after a health setback. When paired with clinical health aide services, non-clinical caregivers can help a patient recover from a surgery or illness sooner by eliminating the stress that comes with staying in an unfamiliar place. Plus, less time in a hospital can mean less exposure to germs and a lower risk of infection.
  • Reduced risk of reinjury or rehospitalization. While it’s the place where seniors feel the safest, home is where most injuries to seniors occur. For instance, the majority of fatal falls experienced by seniors occur in their own bathroom and the risk of burns and scalding while cooking increases significantly due to impaired mobility and decreased reaction time. By assisting seniors with these activities, home care aides can help them stay out of the hospital for as long as possible.
  • Lower costs for care. Until the recent CMS changes, Medicare Advantage program members or their families were left to pay for home care out of pocket. With some Medicare Advantage plans now covering up to 20 hours of in-home care a month as a supplemental benefit and up to 100 hours per quarter if a patient is in a chronic care management program, seniors may no longer have to spend their life savings on personal care services.
  • Higher quality of life and patient outcomes. Loneliness and social isolation are two of the greatest threats to a senior’s health, increasing their risk of dementia, heart attacks, stroke, and premature death. When family or friends can’t be there, home care aides can provide the companionship seniors crave, helping them enjoy their favorite activities, and if needed, drive them to places where they can socialize, such as the hairdresser, an exercise class or their preferred house of worship.

Benefits to Family Caregivers When Medicare Advantage Plans Cover Home Care 

The care of seniors often rests on the shoulders of family members, in most cases a spouse or a child. Twenty-nine percent of the U.S. population is caring for a chronically ill or older family member, spending an average of 20 hours per week on their care. This is a heavy responsibility for family caregivers financially, physically and emotionally.

While Medicare Advantage plans typically focus exclusively on seniors age 65 years and up, the health plans of which they’re a part focus on other segments of the population, including Individual & Family and Group. Helping seniors directly impacts customers in these segments too in a variety of ways that can have lasting loyalty implications.

  • Decreased stress levels. The average caregiver is a woman in her forties with a job and children of her own—finding a balance between all three can be exhausting. Twenty-two percent of caregivers report that their own health has gotten worse due to the stress of caring for a loved one. Home care and respite care ease the burden by helping seniors manage their daily activities so that when the family member is present, they can concentrate on what they want to do most after a busy day—relax and enjoy quality time with their loved one.
  • Greater peace of mind. When a caregiver can’t be with their loved one because of work or because they live hours away, a home care provider provides them peace of mind, knowing their spouse or parent is receiving premium care. Depending on the agency or platform, personal care aides can also keep loved ones updated on the patient’s condition in real time through mobile applications and digital dashboards.
  • Lessened financial burden. Just as there are physical and psychological strains associated with caregiving, there is also the financial strain. Because many caregivers have to cut their hours at work or leave their jobs altogether to stay with their loved one, AARP reports they can lose up to $304,000 in wages and benefits over their lifetime. In addition, children will spend an average of $140,000 out of pocket to care for a parent with long-term needs. When Medicare pays for care through supplemental benefits, it eases the financial weight on families.

By decreasing stress levels and increasing family caregivers’ ability to maintain their own health and wellness, plans provide the long-term effect of improved health among potential future beneficiaries and increasing loyalty. Family caregivers are better able to practice a healthy lifestyle and build a relationship with their own physicians, preventing or reducing the effect of chronic conditions in their own lives. This indirectly saves on future healthcare costs for individuals and provider plans. It may also assist with lower acquisition costs.

Other Home Care Options for Medicare Advantage Plans

For Medicare Advantage plans seeking providers who can help them offer home care benefits to their Medicare Advantage membership, we’ve covered home care, there are at least four major options.

  • Home care. Home care organizations provide the type of non-medical care that is at the center of CMS’s recent policy changes. These agencies, and caregiver marketplaces provide professional aides who assist seniors in home with activities of daily living and social determinants of health.
  • Home hospice. Home hospice is end-of-life care that enables patients to be comfortable and free of pain at home.
  • Home therapy. Home therapy includes infusion, respiratory, occupational, speech and physical therapy, though infusion therapy accounts for nearly 65% of this industry’s revenue. Infusion therapy includes intravenous administration of nutrients, antibiotics, chemotherapy drugs, pain management drugs and other medications.
  • Traditional home healthcare and home nursing care. Many, if not most, health plans and systems are already familiar with traditional home health care and home nursing care agencies. These healthcare professionals are typically certified and provide medical care in a patient’s home.

Bringing Home Care to Medicare Advantage Plan Members

The continued shift to patient-centered care in the health marketplace has been life-changing for patients and cost-saving for insurance plans. With avoidable chronic diseases accounting for 75 percent of healthcare spending in the U.S. according to the CDC, it becomes even more vital to provide the preventative care and monitoring that will reduce spending in the long run. Home care services that reduce the risk of long-term treatments and hospitalizations provide an excellent return on investment for patients, families, healthcare systems and payers. By partnering with a home care provider with a proven record of maximizing patient outcomes, payers can deliver the services their members need while maintaining a healthy bottom line.

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