As In-Home Care Providers Embrace Medicare Advantage, They’ll Need to Better Manage Vulnerable Populations

For years now, the U.S. health care system has steadily moved away from a fee-for-service environment toward value-based care. Medicare Advantage (MA) growth reflects this shift, particularly when it comes to the wide spectrum of home-based care.

Currently, the average home health agency gets about 55% of its funding from fee-for-service Medicare, Medicare Payment Advisory Commission (MedPAC) statistics show. MA accounts for roughly 15% of the average agency’s reimbursement stream — a noticeably higher percentage than just even a few years ago.

Although most still operate primarily under private-pay models, non-medical home care providers are increasingly turning to MA, too, propelled by innovative rulemaking from the U.S. Centers for Medicare & Medicaid Services since the start of 2018.


But as home health and home care organizations more frequently work with MA, they need to keep one thing in mind: The needs of MA beneficiaries are typically far more complex than those of their peers in traditional Medicare.

And in order to succeed at managing these populations, home-based care beneficiaries need to have a firm grasp on social determinants of health (SDoH).

“We are standing on the cusp of an explosion in MA plans looking for proven solutions to addressing SDoH,” Allison Rizer, a principal at ATI advisory, told Home Health Care News in an email. “The policy environment is increasingly supportive of this, but the evidence is still lagging. MA plans need partners who really understand their business environment and how to address member needs in a way that improves overall performance.”


Washington, D.C.-based health care consulting firm ATI Advisory and the Better Medicare Alliance (BMA) analyzed the SDoH needs of MA beneficiaries in a new data brief released on Tuesday. BMA — also based in D.C. — is a research and advocacy organization aimed at supporting Medicare Advantage policy. 

Rizer was the lead author of the brief.

Social determinants of health are defined by the World Health Organization as the “conditions in which people are born, grow, work, live and age,” in addition to “the wider set of forces and systems shaping the conditions of daily life.” That definition extends to a person’s economic circumstances, educational background, access to food and more.

“Social determinants of health have been shown to impact as much as 50% of an individual’s health outcomes,” Allyson Y. Schwartz, president and CEO of the Better Medicare Alliance, said in a statement. “This data brief finds that Medicare Advantage beneficiaries face higher social risks and real challenges to managing their health.”

When it comes to economic circumstances, MA beneficiaries are more likely than those in traditional Medicare to be “low income,” as defined by the federal poverty level, according to the ATI Advisory data brief. About half of MA beneficiaries have incomes below 200% of the federal poverty level, compared to 41% of beneficiaries in traditional Medicare.

Source: ATI Advisory and the Better Medicare Alliance

Digging into economic circumstances further, more than half of MA beneficiaries living below the poverty line are from a racial or ethnic minority group, compared with 42% in traditional Medicare. That higher percentage is even more pronounced for beneficiaries in lower income brackets.

“This data brief shows that Medicare Advantage is serving a more complex and at-risk beneficiary population than many first knew – and yet it is consistently meeting their health coverage needs,” Gary A. Puckrein, president and CEO of the National Minority Quality Forum, said in a statement. “[We] know that Black seniors continue to live with disproportionately higher social risk factors, and their care is of our utmost concern.”

Meanwhile, in regard to academic accomplishments, 19% of all MA beneficiaries have completed less than a high school degree — a far lower percentage compared to their fee-for-service Medicare peers. That’s an important consideration, the data brief notes, as education is a strong predictor of health outcomes.

Finally, MA beneficiaries are more likely than those in traditional Medicare to speak English as a second language — or not at all. They’re also more likely to face food insecurity.

Source: ATI Advisory and the Better Medicare Alliance

While the ATI Advisory data brief does not call out home-based care providers directly, it offers them a helpful roadmap as they expand deeper into the MA world.

For example, its findings suggest that home-based care providers with strong nutritional programs in place may have an edge in caring for MA populations.

The same holds true for providers with specialized teams dedicated to caring for certain communities and cultural backgrounds. 

Tuesday’s data brief is part of a series of briefs from ATI Advisory, which plans to continue exploring socioeconomic vulnerability across Medicare populations.

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