Three in four Americans, aged 65 and older, have multiple chronic conditions, according to the Centers for Disease Control and Prevention (CDC).
These illnesses affect both health outcomes and health costs. The CDC cites chronic conditions as the leading cause of death and disability. It also reports: 90% of U.S. healthcare spending covers chronic and mental health conditions, and multiple chronic illnesses account for 93% of Medicare spending.
Chronic Care Act: Promoting Coordination in Home Care Delivery for Chronically Ill Patients
In an effort to enhance the health of individuals with complex needs—and control costs, policymakers passed the Bipartisan Budget Act of 2018 (BBA 2018), which includes provisions from the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, S. 870, first introduced by Senator Orrin Hatch (R-UT) in 2017.
BBA 2018, signed into law by President Donald Trump in February 2018, will further promote the coordination of home care delivery by enhancing accessibility to care and providing flexibility for the coverage of social services.
Enhancing Accessibility to Care
Results of a study published in the Journal of the American Medicine Association found that an estimated two million adults over the age of 65, or nearly six percent of the American Medicare population, are completely or mostly homebound.
These persons—many chronically ill and often bed- or chair-ridden—need high levels of medical care but have difficulty accessing it on a regular basis, outside of emergency situations—if then. In fact, only 12% of the study’s participants received primary care services at home.
Independence at Home Demonstration Program
In 2012, CMS launched its IAH service delivery and payment incentive model to provide chronically ill and disabled Medicare beneficiaries with home-based primary care (HBPC) visits from doctors, nurse practitioners, and care teams.
“When a critically-ill patient can remain in familiar surroundings,” said former CMS Acting Administrator Marilyn Tavenner in a press release, “the benefits are many: the person retains greater control over their daily lives, families and caregivers report greater satisfaction with the care, and unnecessary hospitalizations are avoided.”
Established under Section 3024 of the Affordable Care Act, IAH reaches beneficiaries with:
● At least two chronic conditions
● At least two functional dependencies
● A non-elective hospital admission within the last year
● Acute and subacute rehabilitation services within the last year
● Coverage from fee-for service (FFS) Medicare
The program fosters a multidisciplinary approach to care, and the results have been promising:
IAH delivered patient-centered care in the home setting—and saved Medicare over $25 million, an average of $3,070 per beneficiary, in its first year.
In its second year, IAH saved Medicare $7.8 million, or an average of $89 per beneficiary. It also reduced the number of hospital readmissions and emergency room services for chronic illnesses.
Years later, the program continues to deliver primary care in patients’ homes—most recently receiving a two-year extension and an increased beneficiary cap by the Chronic Care Act.
Providing Flexibility for Coverage of Social Services
Social support is critical to the well-being of chronically ill patients.
“Whilst health services themselves are important for health,” according to a study published in the International Journal of Integrated Care, “they are not the only relevant services – essential to good health is good nutrition, domestic and personal hygiene, access to technical aids, safe housing, and socialization.”
In agreement, many providers now focus on integrated care: addressing clinical and non-clinical, or social determinants of health (SDoH), factors in their provisions of whole-person care and treatment.
Benefits for Long-Term Support Services
The challenge? Payment. The traditional fee-for-service (FFS) payment model makes it difficult to bill for nonmedical services.
The Independence at Home Demonstration, however, is a newer, innovative model that provides the financial support necessary for delivering home-based care to chronically ill patients.
And as healthcare continues its transition to value-based reimbursement, the Chronic Care Act will not only encourage nonparticipating IAH healthcare providers to target and serve Medicare beneficiaries with complex needs, but it will also give healthcare organizations much-needed flexibility to provide for their patients’ social needs, including long-term support services—directly or indirectly through community partnerships and referrals.
A new category of Medicare Advantage (MA) plan benefits, Special Supplemental Benefits for the Chronically Ill (SSBCI), will make this possible. These plans will cover “non-primarily health related supplemental benefits that address chronically ill enrollees’ social determinants of health so long as the benefits maintain or improve the health or function of that chronically ill enrollee.”
Essential to the well-being of older adults with complex chronic conditions is the provision of their health and social needs. Often homebound and dependent on others for long-term support, technology-enabled home-based primary care is an option for service delivery, care coordination, and effective communication that guides individualized care for such patients, betters their quality of life, and helps them remain safely in their homes