US expands Medicare: insurance will now cover more when caring for the seriously ill

The federal agency that administers Medicare, the Centers for Medicare and Medicaid Services (CMS) is finally recognizing what people have known for thousands of years: family members are the backbone of care for frail old and young people with disabilities. Therefore, the agency is taking important steps to help them. The edition told in more detail Forbes.

Photo: IStock

The key is that, for the first time, Medicare will pay doctors and other health care providers to provide critical support to the families of people with certain medical conditions.

Medicare Advantage and other health insurance models have been able to provide some of this support. For years, CMS has held the view that Medicare fee-for-service can only cover services offered directly to beneficiaries, not to family members caring for them. This will change soon.

The agency will:

• pay Medicare providers, including doctors, certain nurses, and therapists, to train family caregivers;
• pay for social needs assessments and navigation to care for people with certain medical conditions;
• create an integrated care model for people with dementia and their families.

On the subject: Care for the Elderly and the Terminally Ill: What Services Does Medicare Cover?

Nurse training

First, CMS will generate a billing code to pay health care providers—including doctors, nurse practitioners, physician assistants, speech therapists, physical therapists, and occupational therapists—to teach family members how to care for their loved ones. The new payment will begin next year and, apparently, will allow for both individual and group training.

This is a great idea and long overdue. Today, families are expected to provide often complex care to patients living at home with little or no training. They are supposed to magically know how to do everything from wound care to transferring a patient from bed to chair.

Training will be a huge advantage. But who will actually do it? Many physicians know little about many of these skills and do not have the time or opportunity to teach others. Physicians can bill for treatment, but nurses or therapists will do the best job.

The proposal assumes, among other things, that this training will take place in health care settings, like all Medicare Part B services. However, this is contrary to actual experience. Overworked family members are unlikely to come to a doctor or physical therapy center to receive such training.

The new payment model will allow physicians to outsource this work to community organizations such as adult day centers and senior centers and similar groups. The problem is that they are generally not Medicare providers.

Care navigation

The second initiative will allow Medicare to pay for a social health needs assessment and, last but not least, care choice assistance. Importantly, this new payment rule will allow physicians to partner with non-medical providers, including community service organizations and local health professionals who are best placed to do the job.

But it is limited, at least for now, to certain "high-risk states." CMS should define this concept as broadly as possible, focusing on those conditions for which patients can benefit most from needs assessment and care choices.

Integrated care for people with dementia

The third reform will target specifically families caring for loved ones with dementia.

The Guide to Improving the Dementia Experience (GUIDE) is an eight-year program that aims to provide a package of care coordination and management, caregiver training and support, and recreation services.

This program, scheduled to launch next year, is exactly the model of fully coordinated care that people with chronic conditions need.

Some of the nation's most creative comprehensive care programs for people with dementia have come to a standstill because Medicare (and Medicaid) didn't pay for them. This innovation has the potential to change that.

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The Importance of Family Caregivers

Yet many questions remain today. How much will Medicare pay for these services? How often can they be offered? What is a family guardian? Will medical practitioners be willing to participate in the program? What many have not yet done with other alternative Medicare payment models?

Despite their limitations, these initiatives by US President Joe Biden's administration are a huge step forward. They promise to break down some of the biggest barriers to effective care and enable people with chronic illnesses to live at home longer. Most importantly, they show how important family caregivers are.

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