For the past few years, the foundation has supported efforts to increase access to high-quality care for high-need patients in the community and in their homes – the places they want to receive it most. A typical high-need, or seriously ill, patient has multiple chronic conditions such as diabetes, heart disease and chronic obstructive pulmonary disease, and they are also limited in their ability to perform everyday tasks such as eating, bathing and walking.

People with serious illness also have complex needs that require significant care planning and coordination, as well as use of a wide range of services. In addition to acute and chronic care provided in hospitals and clinics, seriously ill individuals often require home-based and community-based services to address their non-medical needs. These services include home care, social services, transportation and help with household activities. Caregivers of these patients need services as well, such as respite care, which gives them a break from their usual caregiving duties.

Assessing gaps in health benefits

Health benefits are defined as health care items or services covered under a health insurance plan – offered either by a private insurance company like Aetna or by the government such as Medicare. When properly designed, health benefits for seriously ill individuals and their caregivers can support high-quality affordable care that is aligned with a person’s preferences and needs. If they are not designed correctly, health benefits may fail to address the needs of seriously ill individuals, and can result in significant financial barriers that prevent them from receiving necessary care.

The foundation recently commissioned Discern Health, a health care consulting firm, to review the current health benefits landscape and assess how benefit structures affect access to serious illness care in the community. Discern Health’s recommendations are summarized in a new Health Affairs blog and also discussed at length in a full report.

The report identified three main problems with how health benefits are currently designed for seriously ill individuals:

  • High-deductible health plans limit access to needed care. Medicare, Medicaid and private insurance cover a wide range of services, but cost sharing (i.e., the portion of expenses that patients are required to pay out of pocket) limits access to health care, especially within high-deductible health plans and fee-for-service Medicare. High-deductible health plans (those with a deductible of $1,350 or more for an individual or $2,700 or more for a family) are becoming increasingly common among both employer-sponsored and health insurance exchange plans. A recent study found that high-deductible health plans result in underutilization of needed services, especially for low-income individuals. If people with serious illness forgo needed services, pain and other symptoms can go unmanaged, and overall health may decline more rapidly.
  • Home-based and community-based services are not usually covered by insurance. Home- and community-based services can help alleviate financial and emotional burdens for the seriously ill and their caregivers. However, despite recent policy changes in Medicare Advantage offered by private insurers, benefit designs continue to restrict access to home- and community-based services in favor of institutional care (i.e., in nursing homes). This is happening despite individuals’ preferences to receive services at home and in the community.
  • Additional insurance to cover gaps in health care is unattainable for most people. While long-term care insurance can help address access gaps, this kind of insurance remains out of reach for many due to high premiums (the amount the policy-holder pays to the plan to purchase coverage).

In order to address these key issues, the report recommends the following:

  • Expand use of value-based insurance design in lieu of high-deductible health plans: Value-based insurance design refers to insurers’ efforts to structure cost sharing and other health plan design elements to encourage enrollees to consume high-value clinical services – those that have the greatest potential to positively impact enrollee health. This approach is particularly relevant to serious illness care because these individuals have complex needs and are rarely incentivized to seek out high-value services, such as care planning and palliative care. While the recently signed Bipartisan Budget Act of 2018 permits the use of value-based insurance design in Medicare Advantage plans nationwide starting in 2020, it remains relatively uncommon in private health plans.
  • Reduce barriers to receiving home- and community-based services in Medicare and Medicaid: Currently, the main provider of home- and community-based services is Medicaid, which is the jointly funded, federal-state health insurance program for low-income people. Medicaid eligibility levels vary by state, but a family of three earning about $40,000 per year will typically qualify for the program. Medicare, the federal health insurance program for people who are 65 or older, has not traditionally covered home- and community-based services. However, in a major step, the Centers for Medicare & Medicaid Services recently announced that Medicare Advantage (the private health plans that enroll one-third of all Medicare beneficiaries) will be allowed to cover certain home- and community-based services beginning in 2019. This change to Medicare Advantage is described in another new Health Affairs blog; several of the blog’s authors are from the Center to Advance Palliative Care, which is also a Moore foundation grantee. The permitted supplemental services include assistance with activities of daily living (eating, bathing, etc.), home-based palliative care and adult day services. It is important to note that these supplemental services are optional for Medicare Advantage plans, and it remains to be seen how many plans will opt to provide this coverage and how much it will increase premiums for enrollees.
  • Allow penalty-free withdrawals of retirement savings to purchase long-term care insurance: Long-term care insurance provides a financing alternative for individuals who need long-term care and do not qualify for Medicaid. Only about 11 percent of individuals ages 65 and older have long-term care insurance, mostly due to its high cost. Congress can take steps to promote increased access to long-term insurance by, for example, allowing individuals to make penalty-free early withdrawals from 401(k) and IRA retirement savings accounts to purchase this insurance. Such a policy change would result in 8.5 million new long-term care insurance enrollees, according to estimates from the Bipartisan Policy Center.

Ongoing efforts

The new Health Affairs blog and the full report serve as valuable resources for health care providers and payers as they work to deliver high-quality care to high-need patients. At the foundation, we are currently working with grantees on several projects related to community-based serious illness care and we look forward to updating you on this work moving forward.

Learn more about the Moore Foundation's work in serious illness care

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