keywords: Centers for Medicaid and Medicare Services (CMS), Medicaid, Medicare, federally qualified health centers (FQHC), Medicare Advantage plans, health policy in the United States, social determinants of health (SDOH), patient-centered medical home (PCMH), accountable care organizations (ACA), community health, population health
themes: evidence-based health care, addressing social determinants of health (SDOH) to decrease societal health care costs, addressing SDOH to improve individual health outcomes, public health, health policy
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Community News on U.S. Health Policy, Research, and Measuring Patient-Centered Outcomes (Metrics): Medicare the CHRONIC Care Act
You know how hit or miss, depending on your region, the Medicare Advantage plans are on covering acupuncture the past couple years? Ever wonder why the Advantage plans have more variability than standard Medicare? This article from
JAMA that touches a bit on Medicare Advantage plan flexibility and the 2018 CHRONIC Care Act helped me better understand this and how it has impacted coverage of acupuncture services.
Medicare Advantage programs (not to be confused with regular Medicare) are allowed to be innovative. In fact, you may have noticed several programs are leading the way on innovation and coverage of integrative health services and other wellness-promoting and function-promoting services.
Some of this innovation is in response to recent federal health policy initiatives to address social determinants
of health (SDOH) in patients and patient populations with chronic health conditions.
The following July 2019 study, "Perspectives of Medicare Advantage Plan Representatives on Addressing Social Determinants of Health in Response to the CHRONIC Care Act" looked at how these insurance
companies were responding to the Medicare incentive from innovative ideas to limits.
acronym of "CHRONIC" stands for: "Creating High-quality Results and Outcomes Necessary to Improve Chronic care" aka the "CHRONIC Care Act of 2018"
Connection to Integrative Health (IH)
The IH paradigm looks at a person as a garden, as part of
a larger system that includes their environment and community. Some
Medicare/Medicaid advantage programs have begun covering IH care, including services
provided by acupuncturists as related to its large evidence base demonstrating improved health
outcomes. Medicare Advantage program patients can receive care at private practice clinics or
hospital-based outpatient clinics.
Why This Policy Change and Its Implementation is Important
According to the paper, “The passage of the Creating High-Quality Results and Outcomes
Necessary to Improve Chronic (CHRONIC) Care Act in 2018 allows Medicare
Advantage (MA) plans, which enroll more than one-third of Medicare beneficiaries,
greater flexibility to address membersʼ social determinants of health (SDOH) through supplemental benefits.”
“To provide more benefits to address SDOH, MA plans may learn
from the experience of other payment models in expanding their service
offerings. While, to our knowledge, there is no evidence to date of how MA plans
can better address SDOH, flexibility has existed to address SDOH and other
patient needs in patient-centered medical homes, 36 accountable care organizations
(ACOs),10,37-41 and Medicaid Managed Care. 42-44" [emphasis added]
Challenges these companies have when they are innovating new patient care coverage plans that address social determinants of health
- finding strong evidence base for types of clinical care or procedures that show improved patient outcomes
- finding evidence base for cost-effectiveness
- finding partners who can provide these evidence-based services
- getting clear guidance from CMS about what is permitted
"In particular, ACOs may face
many of the same challenges as MA plans as they begin to take on more capitated
risk, i.e., the need for a strong evidence base that addressing SDOH may
improve patient outcomes and reduce costs, the ability to find partners who can provide these services, and clear guidance from CMS about
what is permitted.39"
"In a 2014 qualitative study (38) of ACO perspectives on SDOH,
ACOs, similar to MA plans, were interested in expanding these types of benefits but did not always know how." [emphasis added]
"The Hennepin
model, (41) in which a Medicaid Managed Care agency partners with a hospital, a community
health center, and the county department of health to better coordinate services,
is often seen as a successful example of how organizations can address SDOH
through community partnerships."
"The past successes of Medicaid Managed Care in addressing
SDOH may be an even more relevant example to MA plans on how an insurer can
best address these concerns.(10)” [emphasis added]
Citation: JAMA Netw Open.2019;2(7): e196923. doi:10.1001/jamanetworkopen.2019.6923
More information about Medicare Advantage Programs (updates added 9.30.2019)
