Policy & Regulation News

AHA Calls for Personalized Care Access in Medicare Advantage

The organization says MA should account for better access to care via telehealth and offer personalized care that overcomes social determinant barriers.

AHA says Medicare Advantage should include more personalized patient healthcare access provisions.

Source: Thinkstock

By Sara Heath

- Medicare Advantage (MA) plans need to include more personalized care access options to meet patient needs, said the American Hospital Association in a recent letter to the House of Representatives.

AHA submitted its letter to the House Ways and Means Committee to respond to a June 7, 2017, House hearing on promoting integrated and coordinated care in MA.

“In most instances, insurers must provide all plan enrollees with the same set and scope of benefits,” the organization wrote. “We recognize that such a policy is intended to prevent discrimination and ensure access to care for all enrollees. However, this requirement has the negative consequence of preventing plans from addressing the unique needs of some enrollees.”

For example, one subpopulation of MA patients may benefit from a specific service option. However, Medicare cannot offer it because of the prohibitive costs associated with offering that service to all MA beneficiaries.

AHA urged Congress to reconsider more flexibility for the MA program, allowing it to deliver these more individualized treatment options based on beneficiary needs.

READ MORE: What Providers Should Know to Improve Patient Access to Healthcare

“Consistent with existing oversight mechanisms, CMS could continue to monitor that all beneficiaries are receiving the care that they need and that such policies are not unintentionally resulting in adverse outcomes,” the organization recommended.

AHA also called on Congress to allow MA to offer more services to meet individual social needs.

Patient healthcare and wellness are determined by more than just doctor visits. The social determinants of health – defined as social, environmental, and socioeconomic factors that influence patient health – also dictate patient wellness.

“MA plans currently have limited options for providing non-medical social services to help address these underlying social determinants of health,” AHA wrote. “We encourage Congress to allow plans to offer non-medical social services and include the costs associated with these services in their bid amounts.”

Integrating the social determinants of health into health plans could have several positive results.

READ MORE: Bill Targets Patient Access to Pharmacy Care in Rural Areas

“These factors often cannot be addressed by medical services alone, yet may be the primary drivers of health status and outcomes, as well as health care utilization and total spending by Medicare and other payers,” the organization added.

As a part of its social services advocacy, the AHA also suggested Congress create options that might make it easier for a patient to stay in their own homes when patient health begins to deteriorate. The organization said MA should cover personal care options and remote patient monitoring tools to allow better at-home care.

“Such services have a number of benefits: patients typically prefer staying in their homes, the home can be the most efficient site of care, and providers can often detect new or deteriorating conditions earlier in the disease progression, thus resulting in more efficient use of health care resources and better outcomes,” AHA explained.

Additionally, AHA called on Congress to consider social factors during payment discussions. The organization lauded recent changes to the Hierarchical Condition Categories (HCC) risk-adjustment model, but argued that it does not go far enough to account for extenuating patient circumstances. Congress must call for a more patient-centered formula for modifying payments.

“Better accounting of sociodemographic information, where appropriate, will ensure that plans are adequately reimbursed for more complex patients,” AHA explained. “Failing to account for these factors when establishing reimbursement rates can harm patients and worsen health care disparities by diverting resources away from plans serving large proportions of disadvantaged patients and their network providers.”

READ MORE: Patients Want More Access to Telehealth, mHealth Treatment

AHA also acknowledged the advantages to adding telehealth to MA plans. Telehealth has proven an effective option for extending more timely or convenient access to healthcare, especially for patients living in rural areas.

“Congress should pursue all avenues to expand access to services via telehealth, including removing barriers caused by the geographic location and practice setting ‘originating site’ requirements and restrictions on covered services and technologies,” AHA asserted. “MA plans also should be permitted to submit costs associated with telehealth as part of their bid amounts.”

Geography and originating site requirements have long hindered the expansion of telehealth and its integration into CMS health plans. Healthcare professionals debate licensing issues and whether a clinician should deliver telehealthcare to a patient in another state.

AHA contended that Congress should overcome these barriers to make telehealth a more viable and open option to expand healthcare access.

The organization concluded by reiterating its plans to work with Congress and CMS to ensure the MA program works for all beneficiaries.

“We remain deeply committed to working with Congress, the Administration, Medicare beneficiaries and other health care stakeholders to ensure a high-performing MA program for the millions of seniors who rely on the program today and in the years to come,” AHA concluded.


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