In recent years, public health researchers have joined with health plans and provider organizations to better understand and document treatment of patients with complex health care needs. There is emerging consensus around common elements of successful care models, strategies for stratifying risk to target services for improved outcomes, and the importance of addressing social determinants of health, particularly for low-income patients.
Public health experts define social determinants to include a broad array of issues that include but are not limited to: income, employment, and environmental health. However, for the purposes of this discussion, we refer to a limited array of evidence-based interventions that include a subset of many of the health-related services that have potential to improve patient outcomes. These services are not reimbursed under Medicare’s fee-for-service payment structures, and other reimbursement structures may lack the necessary flexibility to address these types of interventions. As a result, the current reimbursement structures fail to adequately reimburse health care providers for services necessary to align existing care models with the growing population of Medicare beneficiaries with multiple chronic conditions and complex needs, making care models fiscally unsustainable over the long-term.
There is emerging consensus around common elements of successful care models and the importance of addressing social determinants of health, particularly for low-income patients.
This report examines reimbursement structures that serve dual-eligible beneficiaries, including Special-Needs Plans in Medicare Advantage (MA), the Program of All-Inclusive Care for the Elderly, and Medicare-Medicaid Plans under the Financial Alignment Initiative demonstration. BPC will issue a second report in 2017 to address similar issues in other Medicare reimbursement structures, including MA, the Medicare Shared Savings Program, and Medicare demonstrations.