By Tyler Overstreet Cromer, ATI Advisory
The needs of Medicare beneficiaries with complex chronic conditions are vast, and the funding to meet those needs is limited. The U.S. traditionally invests heavily in providing health care services for the sick, but relatively little in providing social services and supports. The result is a system that takes care of the sick but does little to support individuals holistically to prevent decline. For example, medical providers cannot prescribe or provide healthy meals or safe housing, the needs for which often lead to expensive health care utilization.
Policymakers took a (small) step in the right direction, when, in 2018, Congress authorized Medicare Advantage plans for the first time to provide non-primarily health-related benefits for individuals with complex chronic conditions — called Special Supplemental Benefits for the Chronically Ill (SSBCI). The Centers for Medicare & Medicaid Services explicitly allows plans to use these benefits to address social determinants of health. There’s no new funding for these benefits, but the authority provides an unprecedented opportunity for plans to do more to support maintaining and improving health for older adults with complex needs by covering things like healthy food, pest control, and non-medical transportation.
Bringing these new benefits to market is not easy, but it is doable. Nearly 1,000 plans are offering at least one of these new SSBCI benefits in 2021, up nearly four-fold from 2020, the first year these benefits could be offered. Plans should capitalize on this opportunity to meet members’ needs and prevent unnecessary and unwanted hospitalizations.
OK, What Should Plans Do Next?
In partnership with the Long-Term Quality Alliance and with support from The SCAN Foundation, ATI Advisory spoke to nearly two dozen plans and providers about their early experiences with these new benefits. From this research, we developed a roadmap, or set of approaches, for bringing these benefits to the members who need them. We specifically identified roadblocks that plans and providers may hit, and ways to overcome them. Following are a few key lessons for Medicare Advantage plans:
1. Get started. There are many ways to begin offering these benefits, but it is important to get the work going by building support internally. One strategy is to ask providers and care coordinators what members need and what they wish they could provide, but currently cannot. This approach allows for two things: (a) providing needed services; and (b) providing services that providers will understand, support, and advance. Plan innovators also report that having evidence about the effects of the provided service — in terms of reduced medical costs and quality improvements — can facilitate success. Plans also reported the value of “testing” a benefit in a smaller plan, especially a Special Needs Plan that is targeted to a specific population. If the benefit proves valuable for a subpopulation, it can then be scaled up to more plans offered by the carrier.
2. Build connections with provider partners. There are providers who want to work with you to provide valuable services. They want to be your partner and many are even willing to take on risk. Look for partners who have a track record of providing high-quality services to customers, the ability to fulfill service requests, a single contact and point of entry for your account, strong communication mechanisms, and who understand how they can support your members.
3. Design a benefit that makes sense for members. Consider benefit options made available through a care coordinator or a flexible benefit design to get benefits to members that they find valuable. Target higher cost benefits to people who truly need them.
4. Educate and spread the word. A common mistake is to assume that if you build it, the members will come. This doesn’t necessarily happen. Plans need a proactive strategy to identify eligible members, reach out to them, and let them know about the benefits available. Plan staff, care coordinators, and primary care providers are also important constituents and communicators — they need to know what the benefits are, who is eligible to receive them, and how to access them.
5. Learn, evaluate, and share what you learn. Make sure that there are mechanisms for providers and care coordinators to share feedback about how things are going. Track uptake and outcomes for individuals who access benefits. And importantly, share what you learn about effective (and ineffective) benefits within the plan and more broadly.
Working together, plans, providers, beneficiaries, government, and other stakeholders have an opportunity to: (1) provide social services and supports benefits to members who need them; (2) strengthen the connections between plans and the social service infrastructure for all Medicare members who can use supports, including — but not limited to — those who qualify for Medicaid; and (3) build the evidence about how interventions really work to keep people well and reduce downstream costs. If we accomplish these goals, we will have a stronger, more integrated health system and a strong case for continued policy support and funding to provide benefits and services that address a broader set of human needs.
With support from The SCAN Foundation, ATI Advisory and the Long-Term Quality Alliance will continue to monitor the experiences of plans and providers in delivering SSBCI in Plan Year 2021 and planning for their Medicare Advantage bid submissions for Plan Year 2022. For more information on SSBCI, please visit our landing page. For more information on a consensus-based vision for how SSBCI can address the needs of all stakeholders, with Medicare beneficiaries as the central focus, see the Guiding Principles for SSBCI.