By Thomas Goldsmith
At a senior center in Asheboro, people dealing with diabetes can learn ways to manage the condition — from healthy eating to stress management — and have Medicare foot the bill.
These diabetes self-management classes, each two and a half hours, require significant work on the part of attendees, said Laura Plunkett, health promotion coordinator for the overseeing Piedmont Triad Area Agency on Aging.
“Throughout the entire class they are making actions plans, they are making goals that they are going to be held to,” Plunkett said.
A doctor’s approval is required for the classes, which represents a change of thinking about how to help older North Carolinians receive Medicare-reimbursed services from sources other than clinics and hospitals. Offerings include services such as these diabetes self-management classes, or a home-delivered meal or a ride to a doctor’s appointment. They’re the types of assistance that can allow many seniors to age while still at home, ideally staying out of emergency departments or nursing home beds.
The federal bureaucracy in charge of Medicare is broadening the types of services that it will pay for to include these supplemental benefits. In the near term, the newly qualifying services will only serve beneficiaries enrolled under Medicare Advantage, coverage run by private insurance companies to administer the public insurance plan.
“Services to more people”
In North Carolina, help of this kind has more typically been paid for through combined federal, state and local funds through the mechanism of Home and Community Care Block Grants. But demand is so great that more than 10,000 North Carolinians are on waiting lists for assistance such as Meals on Wheels and rides to the doctor.
In the recent budget session of the North Carolina General Assembly, legislators declined requests by advocates for older people to add $7 million to the state’s contribution to the block grant funding.
As federal Medicare Advantage funding comes on line for the additional help, the Piedmont Triad Regional Council has several services across its 12-county region that could easily benefit, executive director Matthew Dolge said.
“All we need to do is get different programs certified,” he said.
Beginning in 2019, Medicare Advantage will pay some community-based organizations to provide beneficiaries with help. Across North Carolina, word about the coming funding has been spreading through the state’s Area Agencies on Aging, groups that have spent years or decades running similar programs on sometimes undependable revenue streams.
“That is something we are really excited about,” said Julie Wiggins, who’s transitioning into a role as executive director of the High Country Council of Governments from her post as director of the related High Country Area Agency on Aging.
“We have the existing network or services that would allow us to expand more services to more people.”
Docs must sign off
The federal Centers for Medicare and Medicaid Services, which administers Medicare, says that 2019 and 2020 will bring an expansion of the term “primarily health related”  to include items or services that are used to diagnose or compensate for physical problems, that help reduce the effects of physical or psychological injuries or poor health, or that cut back on emergency department visits or other emergency health care.
[sponsor]To qualify as a supplemental benefit, the service has to focus on the beneficiary’s health needs and must have been recommended as part of a medical provider’s care plan.
Additional North Carolina community-based organizations are already moving forward with approaches that will accommodate the coming changes in CMS’s willingness to cover supplemental services.
“We are working on a pilot with West Health Institute,” said Alan Winstead, executive director of Meals on Wheels of Wake County. “And the premise is that nutrition is one of the social determinants of health,” a factor which can be as important to maintaining health as medical care.
Relationships matter
Meals on Wheels has for many years not only delivered hot meals to vulnerable older people but has also served as an informal social-work role in clients’ lives. Changes at CMS would allow Meals on Wheels, largely staffed by volunteers, to be reimbursed for this outreach into the community.
“We want to get the food to the people and build on our network of volunteers that is getting out to the community,” Winstead said. “We think that there’s value in that health care system.”
Longstanding entities such as Meals on Wheels have often dealt with the same clients for years, giving them a headstart on the private companies that serve Medicare Advantage enrollees.
“Relationships really matter,” said Gina Upchurch, president of Senior PharmAssist, a Durham community-based organization that works with older people helping them obtain and understand their prescriptions. “If I am trying to help Miss Jones with her care and she’s not eating enough, the relationship we have with her is really critical.
“If you are an insurance company calling, you don’t have any idea what’s going on with her.”
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Medicare “Advantage” Plans are exactly the opposite re: mental health/ behavioral health care: NO COVERAGE. I have hassled United Health Care x 8 months to pay me at the 100% Medicare rate Re: a client of mine whom I see in his home and is dying. I have spent 20 hours talking to Optum employees (they outsource their behavioral health) and there is no communication between United Health Care and Optum. We go round and round like a dog chasing its tail. THIS NEVER HAPPENS WITH REAL MEDICARE. Give us a one payer system. Marsha Hammond PhD licensed Psychologist Asheville NC