The 2020 Opportunity: Medicare Advantage as a Market for SDOH Innovation
Supplemental Benefits Never Sounded So Good
Starting in 2020, Medicare Advantage plans will be allowed to offer supplemental, “non-primarily health-related” benefits to help certain eligible chronically ill patients with unmet social needs. Put simply, this represents a large source of reimbursement for social determinants of health (SDOH) solutions in the high-growth MA market.
While this represents a real opportunity for SDOH innovators, we are at an early stage of the rulemaking process where there are far more questions than answers. The Centers for Medicare and Medicaid Services (CMS) recently issued a draft CY 2020 Call Letter that provides guidance on the new rules.
Making the Sausage: MA + SDOH = SSBCI
There are actually two new, and slightly different updates to the supplemental benefits provision under MA. In 2018, CMS announced they would expand reimbursements starting this year (2019) in the MA program for non-clinical supports that promote the health of chronically ill beneficiaries who meet certain eligibility criteria.
Importantly, this 2019 update does not directly authorize benefits that address broader SDOH. The 2019 expansion will be focused tightly on “primarily health-related benefits” like adult day care, caregiver support, in-home supports, home safety modifications and more.
The bill did however, relax the program’s “uniformity requirements” to allow more customized services not only by diagnosis, but also by health status. For certain beneficiaries with complex needs this could include “Z codes” in ICD-10 that document non-clinical needs, such as assistance with self-care, living alone, or living with a dependent relative.
The bigger news for SDOH innovators starts in 2020, and comes with a fun new acronym for your deck of flashcards: SSBCI.
Introducing: Special Supplemental Benefits for the Chronically Ill (SSBCI)
Starting in 2020, SSBCI will amend the 2019 requirements to encompass “supplemental benefits that are not primarily health related and/or offered non-uniformly to eligible chronically ill enrollees […] if certain conditions are met.”
The new outlook for SSBCI, albeit from early on in the rule-making process, appears to offer a broad, flexible set of conditions for innovators and health plans to explore product/market fits for new approaches to address the SDOH. It’s not quite a blank canvas, so let’s take a look at the policy more closely to get a better sense of the business opportunity here.
Product: What Counts as an SSBCI?
If you’re wondering what “not primarily health related” jargon means in plain English, CMS’s explanation may not help:
“MA plans will have the ability to offer a “non-primarily health related” item or service to chronically ill enrollees if the SSBCI has a reasonable expectation of improving or maintaining the health or overall function of the enrollee as it relates to the chronic disease.” (note: this is CMS’s emphasis, not our own 🤔)
Examples of what SSBCI could be: “Such items and services may include, but are not limited to, transportation for non-medical needs, home-delivered meals (beyond the current allowable limited basis), food and produce.”
Examples of what SSBCI cannot be: “capital or structural improvements to the home of the enrollee that could potentially increase property value (e.g., permanent ramps, and widening hallways or doorways)…Additionally, items and services may not be offered to induce enrollment.”
Examples of what SSBCI maybe could be but only time will tell: More broadly, this new ruling has been intentionally designed to provide plans with “broad discretion” — might we see dollars open up for peer supports, CHW, culturally tailored services, financial assistance, or even pet therapy?
Market: Which Beneficiaries (and How Many) are Eligible?
If defining what will be paid for is one key variable in this equation, then the other is defining who is eligible. From the regulation:
“Section 1852(a)(3)(D)(ii), as amended, defines a chronically ill enrollee as an individual who:
1) has one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee;
2) has a high risk of hospitalization or other adverse health outcomes; and
3) requires intensive care coordination.”
As far as what counts as a “chronic condition”, CMS points to the Medicare Managed Care Manual (section 20.1.2 starting on page 5). It’s a broad list spanning metabolic conditions, cancers, rare diseases, behavioral and mental illnesses, substance abuse and more.
So, how big of a market opportunity is this? That is, as yet, unclear — for a few reasons.
First, it’s uncertain how many plans will actually offer these expanded benefits. All signs point to strong interest from the MA market, but the specific numbers vary drastically based on the types of benefits in question. Secondly, given the substantive policy changes described above, any trend from 2018 to 2019 will have little bearing on the number of plans expanding their offerings between 2019 and 2020.
While the number of people and health plans impacted by this will become clear with the passage of time, there are some deeper-rooted challenges here that might not.
Deeper Challenges: Money & Member Engagement
While MA represents a buzzy market to PE and VC, one thing is important to understand: This is not “new money,” it’s a redistribution of existing dollars. CMS is not offering additional funding for new supplemental benefits, but rather providing plans with more flexibility to match resources to needs.
In some ways this new approach resembles a simplified “pay for success” scheme, wherein CMS is allowing MA plans to front the cost of social intervention, prove a positive impact on health, and then promising them a reimbursement. The economics might work out here, but the math is still unclear on how which services are covered, how much they cost, what rate they’re billed, how rigorous CMS intends to be in adjudicating claims, and so on.
For innovators, the Letter states that MA plans must incur “a non-zero direct medical cost” for all supplemental benefits, meaning that in order to be reimbursed for providing a ride or a meal, a plan must invest those dollars into a specific preventative, rehabilitative, or otherwise “reasonable” health impact.
This small clause carries serious potential implications for innovators. If new SSBCIs can only be counted as non-administrative costs, will plans be reimbursed for investing in new technology, or will that count as an administrative expense? The Call Letter hints that CMS’s expectation is that plans make investments in the enabling technology systems on their own:
“MA plans to develop objective criteria (e.g., health risk assessments) and maintain detailed documentation for determining when one chronically ill enrollee is eligible for a particular item or service and another is not. Note that maintaining detailed internal documentation is necessary to address potential beneficiary appeals, complaints, and/or general oversight activities performed by CMS.”
Moreover, the program is entirely voluntary. All of this simply adds up to the likelihood that despite the additional spending leeway from CMS, there are no dedicated budgets and guidelines for 3rd party solutions ala the gold rush days of the HITECH Act. SDOH Innovators are likely to face a competitive sales process requiring a lot of customer education, demos, and brand differentiation. In some ways the MA market opportunity for SDOH innovation may look more like the world of Medicaid MCOs: reimbursement conditions vary from state to state and county to county; those who can do well in one will likely enjoy success in the other.
One of the biggest logistical wrinkles here might be member engagement. Take for instance, CMS’s requirement that plans cannot “induce enrollment” by promoting benefits — this may undermine plans’ ability to drive awareness of the new benefits among seniors or duals, which could undermine engagement and ultimately utilization. If a consumer needs a ride, shouldn’t they be able to pick a health plan accordingly?
As a government program, CMS mandates all these new benefits are subject to ongoing coverage decisions, denials, appeals, etc. None of this sounds consumer friendly or easy to use, and in the first few years of MA plans figuring this out, you can bet it’s not going to go smoothly all of the time.
A related tangled web is the role of community partners. CMS allows for community based organizations (CBOs) to have a seat at the table to do things like help determine eligibility and deliver support, but it won’t reimburse certain plans for services rendered by CBOs. Not only is this shortsighted given how much work and how little money these organizations receive, but it adds incredible confusion to the member experience as far as who is responsible for arranging, delivering, measuring, making decisions, and so on.
2020 & Beyond: Legislation → Law + Innovate → ROI
As part of this rule, Congress is authorizing a five year study by the General Accountability Office (GAO) to analyze frequency of utilization, impact on quality of care, clinical outcomes, and the impact on plans bidding rates for Part C. The report will go on to inform subsequent decisions on funding SDOH supports, ultimately influencing their expansion into Medicare or other insurance programs.
However, given that the US still lacks a definitive sense of what constitutes “ROI” when it comes to social determinants — this report could either become a landmark study, a political football, a red herring or some combination of the above. The closest thing to a crystal ball on this front may be data from the Center for Medicare and Medicaid Innovation (CMMI), which just announced an expansion of its Value-Based Insurance Design (VBID) Model, that also incorporates supplemental benefits based on chronic conditions, or based only on socioeconomic status.
According to the Call Letter, CMS is looking for input from stakeholders by March 1st in two areas:
1. “ CMS solicits comment on whether plans should have flexibility to determine what is a chronic condition that meets the statutory standard (“is life threatening or significantly limits the overall health or function of the enrollee”) and if CMS should consider alternative approaches to determining what meets this criterion.”
2. “CMS is soliciting comments on the limits of these supplemental benefits discussed here and whether we should permit consideration of other factors, like financial need, in determining permissible supplemental benefits for chronically ill enrollees.”
Beyond these areas, there are several other items that we’d like to see more clarification on, including some of the key language (“reasonable expectation”) as well as how plans should think about investing in new technology and business partnerships in light of meeting the new SSBCI criteria.
Zooming out, CMS states the “intended purpose of the new category of supplemental benefits is to enable MA plans to better tailor benefit offerings for the chronically ill population, address gaps in care, and improve specific health outcomes.” To that end, we’ll be keeping an eye on this issue as it develops over the course of the year.
We’d love to hear your questions, comments, and other feedback!
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