Challenges and Opportunities in Caring for High-Need, High-Cost Medicare Patients

Katherine Hayes
G. William Hoagland
Matthew McKearn
Peter Fise
Marisa Workman
Rachel Meltzer
February 2017

This resource analyzes a number of specific care models that serve Medicare-only individuals and enumerates five main policy barriers and potential strategies to address these barriers.  

  • The specific care models analyzed in this report include: Medicare Advantage, (MA) plans, MA Dual-Eligible Special Needs Plans (D-SNPs), Medicare Shared Savings Program (MSSP), Accountable Care Organizations (ACOs), Next Generation (NextGen) ACOs, Comprehensive Primary Care Plus (CPC Plus) Model Participants,  Programs for All-Inclusive Care for the Elderly (PACE) Organizations.
  • The five principle policy issues analyzed in this report include: MA supplemental benefit rules, MA uniform benefit requirements, medical loss ratio application, program integrity rules (anti-kickback and beneficiary inducement), marketing restrictions on communications with beneficiaries, and financial and non-payment barriers.
  • This resource presents initial policy solutions for each barrier identified. The Bipartisan Policy Center will issue final recommendations in April of 2017.
Posted to The Playbook on
Population Addressed
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • What are current regulatory, payment, and other barriers for Medicare-only health plans and alternative payment organizations seeking to provide interventions and social supports which are not covered under the traditional Medicare Part A or Part B benefit?
  • What are policy options that might address these barriers?
Level of Evidence
Expert Opinion
What does this mean?