High-Need, High-Cost Patients

State of Play:  This year, Medicare Advantage (MA) plans are able to provide coverage for a wider variety of nonmedical benefits since the Centers for Medicare and Medicaid Services (CMS) moved to provide better coverage for social determinants of health.  In the past CMS has covered supplemental benefits if they met each of three criteria:  the benefit could not be covered by traditional Medicare, it had to be primarily related to health, and it had to incur a direct medical cost that was not purely administrative.  CMS now allows as a benefit one that can meet any of four criteria. The benefit must diagnose, prevent, or treat an illness or injury; compensate for physical impairments; act to ameliorate the functional or physiological impact of injuries or health conditions; or reduce avoidable emergency and healthcare utilization.  Secretary of Health and Human Services (HHS) Alex Azar has said the Center  for Medicare and Medicaid Innovation (CMMI) is exploring how it can experiment with paying for nonhealth services, such as housing and nutrition.                                                                                  

HLC Position: HLC supports chronic disease prevention and management, which affect the Medicare population at disproportionate levels, as essential components of healthcare delivery through better public and private sector development of evidence-based wellness practices.  As part of various value assessments intended to determine whether new and innovative treatments warrant coverage, HLC believes any new structure should include population health and the long-term benefits of health innovations as criteria over short-term financial concerns, to ensure that these new evaluations do not serve as unwarranted barriers to patient access. Lessons learned from new approaches within Medicare can help lead to more effective ways of preventing chronic disease.   HLC also believes it is important to address social determinants of health and provide greater support for the transportation, nutrition, and other needs that can protect patient health and reduce the need for repeat hospitalization.    More engagement of community health workers is needed to provide enhanced access to healthcare for patients in their homes as well as improved chronic care management. 

HLC Recent Activity:

  • On May 17, HLC held a joint roundtable with Aetna and Tivity Health on addressing social determinants of health (SDOH) in the private and government sector.
  • On May 7, HLC hosted Kelly Cronin, deputy administrator, Center for Integrated Programs at Administration for Community Living, for the High-Need Playbook Implementation Workgroup meeting.
  • On April 5, HLC staff met with Senate Health, Education, Labor, and Pensions Committee staff to discuss the High-Need Beneficiary Playbook.
  • HLC regional directors share the playbook with key stakeholders addressing issues related to telehealth, Stark/Anti-Kickback, and social determinants of health (SDOH). HLC staff sits on the Rural Aging Advisory Council, which is focused on SDOH for 2019.
  • On March 1, HLC responded to the 2020 MA and Part D draft call letter, applauding CMS’s efforts to address social determinants of health through special supplementary benefits for the chronically ill.
  • HLC continues to support the “Preventative Health Savings Act.”
  • On February 22, HLC held a congressional briefing on the patient-centered approach to increasing quality and efficiency of care.
  • On February 21, HLC issued a press release on the High-Need Beneficiary Playbook, providing a framework and specific actions to transform healthcare delivery to high-need patients.