Abstract
Providing quality care for individuals with complex care needs is one of the most pressing challenges facing the United States healthcare system. The Bipartisan Policy Center, with the support of The SCAN Foundation, The Robert Wood Johnson Foundation, The Peterson Center on Healthcare, and The Commonwealth Fund, has been working since 2013 to develop policy solutions focused on how to finance and deliver quality care to individuals with complex care needs.
This report draws from six previous reports to identify a roadmap of policy solutions that can begin to tackle the barriers to financing and delivering high-quality, person- and family-centered, coordinated health and social services and supports to individuals with complex care needs. Individuals with complex care needs have been a population of focus as policymakers have worked to develop and implement program-wide healthcare delivery system reforms in Medicare. In 2010, 37 % of Medicare beneficiaries had four or more chronic conditions. These beneficiaries accounted for 90 % of Medicare hospital readmissions in 2010. Medicare beneficiaries with four or more chronic conditions also comprised 74 % of Medicare program spending in 2010.
Challenges for high-need people can be even greater for low-income older adults and individuals with disabilities who are eligible for both Medicare and Medicaid coverage. Many of these so-called “dual-eligible” beneficiaries have higher medical acuity, significant cognitive and functional impairments, and a greater need for care coordination and assistance with activities of daily living (ADLs).
Looking across BPC’s recommendations to improve the delivery of clinical services and long-term services and supports (LTSS)—a range of health and social services provided to individuals who need help with daily tasks or ADLs—a number of consistent findings have emerged.
The pathway to improving the quality of care and controlling the cost of serving individuals with complex care needs must address the following issues:
A focus on person- and family-centered care, that places a priority on understanding the care goals of families and delivering the services that support them;
An emphasis on coordinating care to ensure that services work across programmatic silos and avoid unnecessary or duplicative care and costs;
Strategies to eliminate programmatic barriers to delivering coordinated care;
Creating a path from medical-driven models that provide care based on what is reimbursed to person-centered models that provide what people need and want;
Support for family caregivers; and
Efforts to identify financing strategies, both public and private, to support the delivery of LTSS
While BPC’s previous work acknowledged that there was no single solution to address the financing of LTSS, the recommendations presented would lead to significant improvements in the financing and delivery of care to individuals with complex care needs.
Insights Results
Overview of report
This report draws from 6 previous reports to identify a roadmap of policy solutions that can begin to tackle the barriers to financing and delivering high-quality, person- and family-centered, coordinated health and social services and supports to individuals with complex care needs
Looking across Bipartisan Policy Center’s recommendations to improve the delivery of clinical services and long-term services and supports (LTSS)—a range of health and social services provided to individuals who need help with daily tasks or ADLs—a number of consistent findings have emerged
The pathway to improving the quality of care and controlling the cost of serving individuals with complex care needs must address the following issues: 1) A focus on person and family-centered care, that places a priority on understanding the care goals of families and delivering the services that support them; 2) An emphasis on coordinating care to ensure that services work across programmatic silos and avoid unnecessary or duplicative care and costs; 3) Strategies to eliminate programmatic barriers to delivering coordinated care; 4) Creating a path from medical-driven models that provide care based on what is reimbursed to person-centered models that provide what people need and want; 5) Support for family caregivers; and 6) Efforts to identify financing strategies, both public and private, to support the delivery of LTSS
This brief highlights several recommendations aimed to improve care for Medicaid and Dual-Eligible beneficiaries including: 1) Modify the definition of “incurred claims costs” in medical loss ratio (MLR) regulations to include the costs of health-related supports and services provided on an in-kind basis to enrollees who are not dually eligible for full Medicaid benefits; 2) Align programs serving dual-eligible beneficiaries to better coordinate care (e.g., align financial demonstrations and coverage standards for benefits that overlap); 3) Expand Medicaid options at home and in the community (e.g., create incentives for states to expand the availability of Home- and Community-Based Services (HCBS) by streamlining and consolidating state plan amendments and waivers and Permit states to offer an innovative LTSS-only “buy-in” for individuals with disabilities whose employment income would result in the loss of Medicaid coverage)
Key takeaways/implications
Moving forward, as policymakers seek ways to improve quality and value in our healthcare system, including demonstrations of alternative payment models under the Medicare and Medicaid programs, as well as implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), there are opportunities to address some of the problems identified in this report. Current and future areas of research and policy development include an increased focus on: 1) Patient-centered care; 2) Further refining reimbursement for patients with complex care needs; 3) The integration of clinical and behavioral health services; and 4) Improving access to care in rural area
