This is the first of a two-part series on serious illness. This first report focuses on changes to Medicare payment and delivery models as well as improvements in access to care through telehealth. The second report will offer recommendations to improve support to family caregivers and to create a more sustainable and viable direct-care workforce.
Americans with serious illness, their families, and caregivers, face significant challenges in the U.S. health care system. They have health conditions that (1) carry a high risk of mortality, (2) limit their ability to live independently, and (3) cause them to rely heavily on caregivers to help them remain at home. Many have trouble performing everyday tasks such as bathing, dressing, and preparing meals, and may be at risk for falls. Individuals with serious illness may live for many years with a health condition. And while those with serious illness span every age, the rapid increase in the number of Americans over age 65 with serious health conditions and functional limitations has spurred researchers and practitioners to focus on and advocate for more effective and person-centered models of payment and delivery of services under Medicare, the primary source of insurance for older Americans.
A study by Discern Health identified key characteristics of payment and delivery that result in the highest-quality care for those with serious illness. Those characteristics include: access to in-home services, including the use of telehealth services; care coordination services; individual care plans based on patient and caregiver needs; and interdisciplinary care teams that communicate regularly and monitor changes in a patient’s health or functional status. Research has also shown that the provision of certain social services and supports not typically covered by health insurance can help those with serious illness remain at home.
Congress and the Trump administration have taken steps in the last year to provide flexibility in Medicare Advantage, Medicare’s managed care plans, that allow health plans to target non-medical health-related supplemental benefits to patients with multiple chronic conditions. While a comprehensive approach to the financing and delivery of long-term services and supports is needed, there are policy changes that, in the short-term, can improve access to services for those with serious illness. The first section of this report recommends changes to Medicare reimbursement. Because traditional Medicare fee-for-service does not cover non-medical health-related services, researchers and many policymakers have concluded that existing payment models must be revised and new payment models developed to provide high-quality care for those with chronic conditions, including those with serious illness.
In many areas of the country, however, fee-for-service is the only option available to Medicare beneficiaries. And though Congress has intervened to increase Medicare Advantage payments as an incentive to plans to offer care, the result has only increased Medicare costs without demonstrating additional value. This report suggests changes in Medicare fee-for-service, in Medicare Advantage, and recommends the development and testing of a serious illness payment model through the Center for Medicare and Medicaid Innovation. This report also outlines barriers to the adoption of telehealth services. While telehealth is not the complete solution to improving care for those with serious illness, telehealth has the potential to improve access to providers in medically underserved areas, both urban and rural. Telehealth services also have the potential to allow patients who have significant functional limitations to receive some services in their homes, where they are more comfortable.
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