Results from a program in Maryland suggest that a Medicare benefit to cover at-home personal care services could be feasible, according to new research findings.
“We think the Maryland experience is instructive,” researcher Karen Davis told Home Health Care News. Davis is professor emerita in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health and a former president of The Commonwealth Fund, a foundation that promotes a high-performing U.S. health care system.
The Maryland initiative dates back to 2014, when the state adopted the Community First Choice (CFC) benefit. This is a Medicaid program, through which the state can offer personal care services to people who otherwise would be eligible for institutional care in a nursing facility and who meet certain income thresholds. To help pay for this benefit, the state’s Medicaid program receives a 6-percentage point increase in federal matching funds.
In addition to assistance with activities of daily living, CFC encompasses other services, including care coordination and home meal delivery. As of 2016, the program had grown to 11,573 enrollees, most of whom were over age 65 and eligible for both Medicaid and Medicare.
While there has been quick enrollment growth, costs have been stable on a per-member per-year basis, at about $21,000, according to Davis and her research colleagues, who recently published their findings in an Issue Brief of The Commonwealth Fund.
Karen Davis et al., Designing a Medicare Help at Home Benefit: Lessons from Maryland’s Community First Choice Program (Commonwealth Fund, June 2018),The majority of expenditures—87%—went to cover personal assistance services.
Many CFC enrollees had been receiving care from family members or loved ones prior to joining the program, and this type of caregiving continued even after they began receiving more formal, paid services. The mean number of informal support hours per week fell from 35.9 prior to enrollment to 28.3 during the program.
“What it really does is augment the total amount of care people get,” Davis said.
While CFC is a Medicaid program, the findings show that a similar benefit could be built into Medicare, she emphasized.
“This is not an out-of-control, costly benefit, it’s a pretty predictable benefit and one that’s pretty essential to ensuring people’s ability to maintain their independence and continue living at home,” she said.
Davis and her colleagues have called for a universal Medicare home care benefit, such as the “Help at Home” model that has been proposed in the past. This would cover a certain amount of personal care per week, with adjustments made based on a beneficiary’s income.
Supporters of the policy say it would enable more aging in place, enhancing quality of life for seniors and preventing them from having to spend down their assets to qualify for Medicaid to cover long-term care. It would also potentially reduce costs across the health care system by preventing expensive medical interventions and institutional care.
The Maryland model
Other states have also experimented with CFC benefits, although their approaches differ, Davis said. For example, California directly contracts with the workers providing the in-home personal care services, whereas Maryland does not.
In Maryland’s “agency model,” certain providers such as private duty home care agencies have been approved by the state to participate in CFC.
“So, the agency is responsible for meeting all labor laws and maintaining quality, so that takes [some burden] off the state,” Davis said.
There are some quality guardrails in place, such as a visit verification system, so that the state can be assured that care is occurring and is of a certain caliber. State-employed nurses also conduct site visits.
Maryland also maintains a database—“LTSSMaryland”—on which it aggregates case management information, billing records and other information.
Next steps
The CFC program is not based on a Medicaid waiver but is a built-in benefit that will be offered indefinitely, as long as the Affordable Care Act remains repealed, Davis noted. That means that over time, further analysis can be done. For example, more investigation could reveal whether the CFC program lowers health care costs by preventing nursing home admissions and reducing hospitalizations among enrollees.
It stands to reason that this is occurring, Davis said. Consider that the per-member, per-year cost is stable at around $21,000 for the program, while nursing home costs far exceed that. A semi-private nursing home room runs to about $86,000 annually, according to the 2017 Genworth Cost of Care report.
The politics of adding a new Medicare or Medicaid benefit to cover in-home personal care are not easy, Davis acknowledged. However, Medicare Advantage plans will be able to offer non-skilled in-home care as a benefit starting next year.
“I do think the expansion of Medicare Advantage is encouraging,” Davis said.
She also cites increasing interest in adding Medicare benefits for dental, hearing and vision care. And she expects that with the aging of the population, the need for expanded benefits will increase and could alter the dynamics among federal legislators and policymakers.
Further research could also help in making the case for a new benefit, and she described the Commonwealth Fund study as a valuable contribution to that effort.
“This is an important study, to ease some of the qualms that people have about adding such a benefit to Medicaid or Medicare,” she said.
Written by Tim Mullaney
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