Editor’s Note: In-home evaluations (IHEs) are an integral component of Medicare Advantage (MA) plans, giving MA plans a cost-effective way to identify and meet the medical and nonmedical needs of vulnerable beneficiaries in their own homes and communities to impact health outcomes. They are an important touchpoint to assess individuals holistically and comprehensively in their own environment and, when possible, connect them to needed community resources and community providers for ongoing care and care coordination.
In a new white paper prepared in partnership with Signify Health, Manatt Health demonstrates how IHEs deliver value consistent with the Centers for Medicare & Medicaid Services’ (CMS) strategic goals for the Medicare program. The white paper, summarized below, also offers recommendations for how CMS could extend that value beyond MA, particularly to Medicare enrollees who are served by Advanced Alternative Payment Models (AAPMs) such as Accountable Care Organizations (ACOs) like those under the Medicare Shared Savings Program (MSSP) or the recently announced ACO Realizing Equity, Access, and Community Health (REACH) Model. Click here to download a free copy of the full white paper and here to read Signify’s recent blog post on extending the reach of primary care doctors into homes and communities by its Chief Medical Officer, Marc Rothman, M.D.
The Value of IHEs
The IHE’s purpose is to provide early, preventive health risk assessments within the home setting for MA beneficiaries. IHEs are perhaps most valuable for those with challenges accessing care, including those who may face barriers to transportation or have physical limitations that prevent them from readily accessing essential health services, as well as those with complex medical and nonmedical health-influencing needs. IHEs are conducted by physicians and advanced practice providers (APPs) and can include:
- Comprehensive health evaluations
- Medication reviews and adherence checks
- Assessments of current and prior health conditions, including those that may not be well managed or are progressing
- Screening for mental health conditions and substance abuse
- Identification of patient safety hazards in the home, such as the absence of shower bars, inadequate lighting, or loose rugs, all of which can have significant impacts on patients’ fall risks
- Connection of individuals to community and medical resources
IHEs can also include other in-home diagnostic and preventive services, such as:
- Lab collection (e.g., HbA1c, LDL, microalbumin)
- Peripheral artery disease testing
- Bone density testing
- Diabetic eye exams
- Flu shot vouchers
Further, IHEs facilitate care coordination for beneficiaries by providing important social determinants of health (SDOH) data to providers and plans in order to support individualized care planning and connect members to relevant community programs.
These features are particularly important for the Medicare program, which covered nearly 61 million beneficiaries in 2021, including adults over 65 years old and younger adults with long-term disabilities, and accounted for a significant portion of the nation’s health expenditures ($829 billion, or 20% of total national health expenditures in 2020).1
IHEs in Medicare Today
Currently, no-cost IHEs are frequently provided as a benefit of MA plans.2 By using medical professionals to assess Medicare members’ health needs in their homes, plans are using the IHE as the foundation for a broader solution to assess and engage an often vulnerable segment of the Medicare population in a comprehensive, person-centered way.
By contrast, providing adequate preventive care is often a challenge within the confines of the original Medicare structure. No vehicle currently exists to offer IHEs on a broad scale in original Medicare or its AAPMs. As a result, the availability of IHEs currently remains limited to MA beneficiaries, who represent less than half (26 million people, or 42%)3 of the total Medicare population.
IHEs Advance Medicare’s Vision for a Patient-Centered, Cost-Effective and Equity-Focused Program
In January 2022, CMS released a Health Affairs article, “Building on the CMS Strategic Vision: Working Together for a Stronger Medicare,”4 which lays out four pillars that will guide the strategic vision of the Medicare program moving forward. These strategic pillars include advancing health equity; expanding access to affordable health coverage and care; driving high-quality, person-centered care; and promoting affordability and sustainability.
IHEs Advance Health Equity
IHEs are essential services that not only align with many of CMS’ broader goals for the Medicare program as a whole but, most importantly, also support patients, providers and payers. IHEs improve patient access to services by bringing care into the home setting, supporting patient-centered care coordination and facilitating accountable care relationships between Medicare beneficiaries and their providers.
Establishing care relationships is especially important for the most vulnerable members of the Medicare population. These include individuals who face social factors that may affect their health and well-being; individuals with chronic conditions, including conditions and needs that may not always be identified in traditional care settings; and individuals who face barriers such as lack of transportation or even physical limitations. As reported by a Harris Poll survey of over 1,000 U.S. seniors (age 65+) in November 2020, over half (52%) say they face barriers to accessing medical or social services.5
For these seniors, the IHE can help remove barriers to care and improve access to preventive care services while fostering long-term care relationships, which are essential in ensuring equitable access to care and improving beneficiaries’ long-term outcomes.6 Further, by conducting evaluations in the home, providers are able to directly observe, contextualize and act on important social, economic and environmental factors that contribute to patient health as strongly as do traditional medical factors.
IHEs Drive High-Quality, Person-Centered Care
IHEs enable targeted medical evaluations, offer providers opportunities to initiate targeted interventions and facilitate the development of person-centered, individualized care plans. Through IHEs, providers are able to identify a range of nonurgent patient needs, such as patient transportation needs, financial needs, poor access to primary care, fall risk and safety concerns, as well as behavioral health issues. Once these nonurgent needs are identified, the evaluation findings can be incorporated into the patient’s care plan. Similarly, for urgent medical needs that are identified through an IHE, providers can make an immediate care referral to the appropriate sources to ensure a timely response.
IHEs Improve Access to Care
For providers, IHEs provide a holistic view of their beneficiaries’ health and social needs in a comfortable, secure setting; allow extra time for health care providers to evaluate and understand the needs of their high-risk members; and alleviate access and equity obstacles for patients by meeting them in the home and performing an evaluation in that setting.7 IHEs also provide a rich source of mental, behavioral, medical, social and demographic data that is generally difficult to collect comprehensively, particularly from certain beneficiaries who may not regularly access health care in their communities.8
IHEs Are Cost-Effective and Can Improve Health Outcomes
By proactively identifying health care needs; providing high-value, preventive health care services and evaluations in home settings; and facilitating care relationships, IHEs facilitate cost-effective care by preventing downstream hospitalizations, reducing unnecessary emergency department (ED) use, and improving patients’ health outcomes in the long term. Additionally, the specific evaluations and services offered within an IHE have been shown to improve long-term outcomes for patients because they facilitate the behaviors and care practices that improve measures of health quality, utilization and cost.
How CMS Can Expand the Benefit of the IHE to a Greater Number of Beneficiaries
In light of the important benefits that IHEs offer the Medicare program through MA as well as the additional benefits that could be codified for broader use in original Medicare AAPMs, CMS can authorize Medicare coverage of IHEs for all Medicare beneficiaries. Or it can establish their coverage for MSSP and REACH ACO-aligned beneficiaries as a payment waiver or beneficiary enhancement. And it can clarify that these ACOs can offer IHEs to their patients as a beneficiary incentive.
CMS Can Cover IHEs as a Benefit in the Original Medicare Program
The most direct way for CMS to address the gap in original Medicare beneficiaries’ access to IHEs is to establish the IHE as a covered service in original Medicare. In the past decade, CMS has established care management as a physician service eligible for coverage under Part B. Likewise, CMS could establish the IHE as a physician service for the same purpose: to appropriately value the time a health professional spends in a beneficiary’s home performing a comprehensive evaluation of the beneficiary’s needs. To formalize the benefit, CMS could establish a standardized G-code or codes that would identify the required services in an IHE and their use. This would allow CMS to track the proliferation of IHEs while being assured that IHEs are performed with sufficient rigor.
CMS Can Create an IHE Benefit Enhancement for Use by ACOs in the MSSP and ACO REACH Model
As a more limited approach to supporting IHEs, CMS could use its regulatory authority to cover the IHE as an original Medicare benefit when it is performed for beneficiaries attributed to MSSP and REACH ACOs. CMS has broad regulatory authority to enhance benefits for beneficiaries in these AAPMs.
Under the MSSP regulations, CMS has the authority to waive payment rules or other Medicare requirements.9 CMS could establish IHEs as an allowable, Medicare-covered benefit for beneficiaries aligned to MSSP ACOs or participants in the ACO REACH Model using payment waivers or benefit enhancements authority. This strategy would provide funding and/or flexibility for a comprehensive IHE, enabling ACO providers to leverage this service while CMS observes its proliferation in the limited setting of AAPMs.
CMS Can Clarify That IHEs Are Permissible ACO Beneficiary Incentives
Another option for CMS to consider is to issue regulatory guidance clarifying that ACOs may offer IHEs as a beneficiary incentive. Medicare ACOs may offer beneficiary incentives to their aligned patients.10 Within the limited framework of CMS regulations, ACOs can offer in-kind items or services that might otherwise be considered prohibited inducements. ACOs may offer these in-kind services so long as there is a reasonable connection between the items and services and the medical care of the beneficiary, the items or services are preventive care items or services or advance a clinical goal for the beneficiary, and the items are not Medicare-covered services.11
The provision of IHEs falls squarely within the ambit of permitted beneficiary incentives. In this scenario, following issuance of favorable guidance from CMS, ACO providers would deliver IHEs as a beneficiary incentive, yet cover the cost of providing them with their own funds.12
IHEs are an integral component of MA plans and can help CMS deliver on its promise to provide equitable, cost-effective and person-centered care, but they need the support of CMS in order to take root in the original Medicare program, and in AAPMs in particular.
1 National Health Expenditure Data: NHE Fact Sheet, Historical NHE, 2020. CMS. Last updated December 15, 2021. Available here: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet#:~:text=Medicare%20spending%20grew%203.5%25%20to,16%20percent%20of%20total%20NHE.&text=The%20largest%20shares%20of%20total,the%20households%20(26.1%20percent). Accessed January 14, 2022.
2 “Taking time to enable better health: Closing gaps in care with in-home evaluations for seniors,” Signify Health. Available here: https://www.signifyhealth.com/infographic-taking-time-to-enable-better-health?hsCtaTracking=e08cc376-f14b-4450-87cc-9de4000f9515%7Cc5e5e427-fcd3-45cc-b869-884df0979899. Accessed January 13, 2022.
3 “Medicare Advantage in 2021: Enrollment Update and Key Trends,” Kaiser Family Foundation. June 21, 2021. Available here: https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2021-enrollment-update-and-key-trends/. Accessed February 11, 2022.
4 M. Seshamani, E. Fowler, C. Brooks-LaSure, “Building on the CMS Strategic Vision: Working Together for a Stronger Medicare,” Health Affairs. January 11, 2022. Available here: https://www.healthaffairs.org/do/10.1377/forefront.20220110.198444/full/. Accessed January 14, 2022.
5 D. Doyle, “Moving Health Home: A New Coalition with a Bold Vision,” Signify Health Blog. March 3, 2021. Available here: https://www.signifyhealth.com/blog/moving-health-home-a-new-coalition-with-a-bold-vision. Accessed January 14, 2022.
6 S. Musich, S. Wang, K. Hawkins, A. Klemes. “The Impact of Personalized Preventive Care on Health Care Quality, Utilization, and Expenditures,” Journal of Population Health Management. December 1, 2016. Available here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5296930/. Accessed February 11, 2022.
7 “Empowering Greater Value in Healthcare,” Signify Health. Presented to the CMS/Center for Medicare team. November 18, 2021 (CM meeting_11.2021 vF).
8 “In-Home Evaluations: Providing Whole Person Care to Medicare Beneficiaries,” Mike Lyle, Director, Legislative Affairs, Signify Health. September 2021 (In-Home Evaluations_Providing Whole Person Care to Medicare Beneficiaries 09.21).
9 42 C.F.R. § 425.612.
10 42 C.F.R. § 425.304.
11 42 C.F.R. § 425.304(b).
12 42 C.F.R. § 425(a)(2).