In the not-so-new realm of nontraditional health coverage, the Centers for Medicare and Medicaid Services (CMS) is expanding their Medicare Advantage plan to include benefits that meet patients “unique health needs” and improve “their quality of life.” Behavioral economics is in full swing these days and now being put to the test by this recent roll out set to take effect in 2019.
Based on the premise that social determinants can drive poor health outcomes and increase costs, equalizing these factors through non-emergent medical transportation (NEMT) as a means to reduce barriers thereby improving care access, providing air conditioners for high risk populations and specific foods for those with diabetes could impact healthcare spending with a hope of yielding greater dividends.
Whether these steps dramatically curtail overall expenditures as opposed to individual relief is not entirely clear.
What exactly is CMS implementing
In a recent statement by the department
“CMS has previously not allowed an item or service to be eligible as a supplemental benefit if the primary purpose included daily maintenance. Under the new policy announced today, CMS would allow supplemental benefits if they compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.”
CMS Administrator Seema Verma pitches the program as such
“Our priority is to ensure that our seniors have more choices and lower premiums in their Medicare health and drug plans…We are focused on addressing the specific needs of beneficiaries and providing new flexibilities for Medicare Advantage plans to offer new health-related benefits. This is a big win for patients.”
How novel is this approach
It is not entirely new as other insurance plans have inconsistently covered transportation costs or alternative adjunctive necessities over the years. But, this concerted effort on the part of CMS is important to watch as Medicare tends to steer the market.
As I wrote previously about NEMT in response to the launch of Uber Health (see here), “Access to transportation is a significant factor amounting to $150 billion lost each year due to 3.6 million Americans delaying or missing medical appointments and interventions, with 950,000 being children.”
A 2016 study entitled Nonemergency Medical Transportation: Delivering Care in the Era of Lyft and Uber, revealed more promising results from a pilot program where Lyft partnered with a NEMT benefit manager offering their services to New York's Medicaid and California's Medicare Advantage patients for preventive and chronic care purposes. They observed a 30% reduced wait time on average, cost per-ride decrease by 32.4% with patient satisfaction at 80.8% (see link here). However, a more recent study in JAMA Internal Medicine investigated the association of rideshare-based transportation and missed primary care appointments. It demonstrated low uptake of ridesharing without decreasing missed appointment rates. Here, the authors suggest better targeting of populations who have such needs and more future research on various delivery mechanisms.
Boston University’s School of Public Health policy analyst Gilbert Benavidez in a piece for The Incidental Economist points to research that suggests
“The United States may be under-spending on social services…Some non-health investments are associated with bigger improvements than those more directly related to health. Investments in education, for example, are associated with bigger returns than those in public hospitals or community health care.”
What does it actually mean
Many countries spend more on social services recognizing lifestyle factors can impose tremendous challenges to optimizing health. This explains, in part, the controversial suggestion last year by a German lawmaker that authorities subsidize paid sex for patients who require nursing care – “the idea is based on a system in the Netherlands, under which applicants must prove a medical need and show that they can’t otherwise pay for a sex worker.” It is hard to imagine here given prostitution is illegal, but sexual and reproductive healthcare are intrinsic to nurturing well-being.
With pets demonstrating well-documented, substantial benefit to mental and cardiovascular health, for instance, is their coverage a given down the line? The test for insurance carriers will likely be whether financial and other costs prove to offset the price of medicines for more severe forms of post-traumatic stress disorder (PTSD) or psychiatric disease, for example.
Any downside?
If all the medical provider needs to do is write a prescription for certain rides or food services as they would any medication, then the task itself is not so prohibitive in the real world of a busy practice. I can’t recall any paperwork related to provisions of care being less than cumbersome and laborious in this arena. So, if that is the case, then exacerbating data entry already plaguing physicians by adding the title of social worker to their job description will be a big win for job dissatisfaction and burnout.
If insurance carriers shift the economic boon toward themselves and away from the patient, then how will that be addressed? Will other costs rise to accommodate this coverage?
The Upside
Efforts have always been underway to get certain less traditional items and activities to be covered. Facilitating healing and maintaining wellness involves a complexity of choices and behaviors beyond physical manifestations. Thinking outside of the box by channeling resources toward fixed, manageable solutions to known problems is a refreshing way to achieve the larger goal of a healthier society. Often our national health policies cast a wide net without understanding the regional and individual disparities people endure that more significantly contribute to disease. This emphasis is moving us in the right direction.
