Medicare in Campaign 2020: Game On

Three news items from the first week of Fiscal Year 2020 are pivotal to 2020 plans for healthcare investors, operators and policymakers. They focus on the future of Medicare. Here’s a recap:

ACO Performance: Monday, CMS Administrator Seema Verma announced that the Medicare Shared Savings Program (aka ACO’s) generated $739.4 million in total net savings in 2018. In her Health Affairs blog, she reported that ACOs that took downside risk reduced spending by $96 per patient compared to $68 per patient for ACOs that did not, and ACO’s led by physicians performed better—$180 reduction per patient—than ACOs led by hospital systems ($27 reduction per patient). Notably, Verma noted that CMS’ MSSP overhaul, Pathways to Success, will require providers to take downside risk after two years while giving them more flexibility to coordinate care for seniors using telehealth and other services. As of July, 10.9 million Medicare fee-for-service enrollees receive care from providers in 560 ACO’s.

Social Determinants: Thursday, CMS convened a roundtable of industry stakeholders to advise on mechanisms whereby social determinants data from its Accountable Health Communities model could be used to improve outcomes. The Accountable Health Communities Model that began in May 2017 allows participating sponsors to screen eligible participants for food insecurity, housing instability, utility needs, transportation needs and interpersonal violence and then refer them to community services programs.

A consortium, Aligning for Health, that includes organizations like Care Journey, Signify and others is pushing CMS to standardize screening criteria for SDOH need as commercial solutions proliferate. Note: a study by the Journal of the American Medical Association published last month found that only 24% of hospitals and 16% of physician practices screened for social needs. Social determinants are critical factors in health services for seniors: thus, CMS wants to advance standardization around SDOH outcomes.

Trump Executive Order: And also on Thursday, President Trump issued an Executive Order “Protecting and Improving Medicare for Our Nation’s Seniors,” that aims to inject competition into the Medicare program in three major ways:

• Permitting Medicare Advantage (MA) insurers to offer supplemental benefits such as telemedicine, adult day, self-care apps along with an expanded role for nurse practitioners and physician assistants to provide direct care.

• Allowing MA enrollees to share in savings they help create vis a vis medical savings accounts and other mechanisms.

• Reducing regulatory constraints that limit innovative care models in both MA and Medicare fee-for-service programs.

The order also includes a directive that HHS set provider payments in Medicare fee-for-service at Medicare Advantage rates and reinforcement of site-neutral payment policy for providers despite pushback by hospitals and a recent court decision that concluded the policy amounted to regulatory overreach.

Choosing the Villages, a retirement community in Florida, as the backdrop for his announcement, the President made clear his intent to pit Medicare Advantage as the GOP answer to Democrat’s favoring Medicare for All in Campaign 2020. This is the President’s 5th Executive Order focused on healthcare and his 3rd in the past 90 days.

MY TAKE

News of the impeachment inquiry dwarfed attention to these three items but they are no less significant. In the aggregate, they reveal the administration’s strategy for Medicare: the federal program that provides coverage for 52.2 million seniors and 8 million disabled costing $732 billion (15% of the federal budget last year).
As opposed to Medicare for All, the administration is asserting that:

• Medicare is the ripe for innovation, especially in the integration of social determinants of health and technologies to improve care coordination. The status quo is not sustainable. Medicare can be improved.

• Traditional fee-for-service approaches are not its future. Providers, insurers and other participants will be expected to assume greater financial risks in addressing the Medicare population. In exchange, CMS is willing to relax its oversight for organizations willing to assume greater financial risk. The door is open to conventional and non-conventional approaches and competition.

• Privately managed Medicare Advantage is the administration’s alternative to Medicare for All.

These three pronouncements come at a critical time for traditional players in healthcare. Hospitals and physicians are struggling to protect their turf against the likes of Walmart, CVS and others who want to disrupt delivery. Insurers are struggling to customize plans for individuals and groups while margins in their fully-insured business erode. And hanging as a cloud over industry sustainability are final rules about inter-operability and the potential for an economic slowdown next year.

More importantly, they come at a critical time for Medicare enrollees: they are not homogenous in their political views, health needs or social circumstances. But they are alike in recognizing that Medicare plays a key role in their lives and politicians talk about it a lot. And they know in Campaign 2020, it’s game on.

Paul

P.S. This week is Mental Health Awareness Week (October 6-12). According to the National Alliance on Mental Illness, 19.1% of U.S. adults experienced mental illness in 2018 (47.6 million people); 4.6% of U.S. adults experienced serious mental illness in 2018 (11.4 million people);16.5% of U.S. youth aged 6-17 experienced a mental health disorder in 2016 (7.7 million people) and 3.7% of U.S. adults experienced a co-occurring substance use disorder and mental illness in 2018 (9.2 million people). Not surprising, prevalence is complicated in populations where their social circumstances are challenging and access to healthcare is limited.

RESOURCES

Verma “Interest In ‘Pathways To Success’ Grows: 2018 ACO Results Show Trends Supporting Program Redesign Continue” Health Affairs September 30, 2019 10.1377/HBLOG20190930.702342

Fraze et al “Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals” JAMA Netw Open. 2019;2(9):e1911514. doi:10.1001/jamanetworkopen.2019.11514

White House “Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors” October 3, 2019 https://www.whitehouse.gov/presidential-actions/executive-order-protecting-improving-medicare-nations-seniors/