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Medicare Advantage plans send seniors to nursing homes

Widowed and usually living alone, Gloria Bailey walks with a cane after two knee replacement surgeries and needs help with cleaning.

So last summer he was thrilled when his Medicare Advantage plan, SummaCare, began sending a worker home to Akron, Ohio, to scrub the floors, clean the dishes, and help with computer problems. Some days, they would spend two hours a week visiting just chatting at their kitchen table. “I love it,” he said of the free benefit.

Bailey, 72, is one of thousands of seniors across the country who visit Papa Inc. employees every week. Known as “Pope Friends,” his main goal is to provide support for the elderly along with helping with light chores and light chores. Since 2020, more than 65 Medicare Advantage plans nationwide have been registered with Papa, a Miami-based company, to address member loneliness, a problem exacerbated by the pandemic.

“It’s better than ever” to counter social isolation, said Anne Armao, vice president of SummaCare. More than 12% of the company’s 23,000 Ohio Medicare members used the Pope’s benefit last year.

But SummaCare and other health plans will also benefit by sending the pope’s friends to members’ homes. Workers can help plan to raise more Medicare money by persuading members to take annual wellness exams, complete personal health risk assessments, and undergo covered health exams.

Following these steps helps you plan in two ways:

By gathering more information, plans may find that members have health issues that can result in higher Medicare reimbursement rates. Plans may increase their star ratings, which are based on more than 40 performance measures, such as cancer tests, diabetes and blood pressure; outcome measures such as hypertension control; and overall satisfaction with the plan. Plans that get at least four stars on a five-star scale receive Medicare bonuses.

Star rating bonus payments represent a growing proportion of federal payments to these private Medicare Advantage plans, which are an alternative to traditional Medicare. In 2021, Medicare paid $ 11.6 billion in bonuses, twice as much as in 2017.

The federal government’s base pay for plans is a monthly fee for each member, but increases that amount based on members’ health risks. Thus, the plans also get billions of dollars a year in additional payments by identifying members’ health problems through a variety of measures, including health risk assessments.

However, federal researchers have found that these diagnoses do not always result in additional treatment or follow-up care for beneficiaries. As a result, the federal government is likely to be overpaid with Medicare health plans and wasting billions of dollars from taxpayers, according to the Medicare Payments Advisory Committee advising Congress.

In a report last September, the Inspector General of Health and Human Services found that 20 Medicare Advantage companies generated $ 5 billion in additional federal government payments for diagnoses identified through health risk assessments and reviews. undocumented graphs that patients were treated for these problems.

Nearly half of those enrolled in Medicare get their coverage through Medicare Advantage.

David Lipschutz, associate director of the Center for Medicare Advocacy, said parents provide a significant benefit to seniors by helping them with homework, reducing their loneliness, and getting them to medical appointments. But the benefit can also help insurers’ results.

“If there’s one thing these plans are good for it is maximizing their profits,” he said.

Medicare Advantage plans often provide physicians with financial incentives for patients to undergo health assessments. Plan workers repeatedly call patients with offers to send nurses or doctors home to complete them. Lipschutz said health risk assessments are only useful if health plans act on the information by making sure patients receive treatment for these problems.

Armao said the health risk assessment and reminders for the annual wellness exams are on the list of things they are told Pope employees ask about at visits.

“It’s our eyes and ears that can learn a lot from the members at home,” he explained. Friends look in the fridges to see if members have enough to eat, check how members feel, and remember to take recipes. SummaCare even directs friends to ask if members have urinary incontinence or are up to date on cancer testing.

Andrew Parker, who founded Papa in 2017 after finding a couple of college students to visit his grandfather, take him to doctor appointments and do other errands, said he estimates his company will offer more than one million company hours in 2022. Medicare plans pay Papa, a for-profit company, a monthly membership fee.

“Dad, father [pals] they are very proactive and will call you to see how you feel and maybe not on the first day, but throughout the program, they may ask you, “Did you know that your health plan would rather have a wellness exam and could help you your health? “he said. “A friend is a trusted advisor who can make them think of benefits they don’t know.”

He said insurers often don’t know a member is facing a health issue until they see a medical claim. “We can identify things they don’t know,” he said.

Until recently, Medicare rarely paid for non-health services. But Pope began working on Medicare Advantage plans in 2020, just a year after the program began allowing private insurers more flexibility to address members’ so-called social needs, such as transportation, housing and food, than they normally do. they are not covered by Medicare but could affect health. The pope’s goal of addressing members’ loneliness became even more important during the pandemic when many older people became socially isolated as they tried to reduce their risk of becoming infected.

The pope has more than 25,000 friends whose average age is 30. Before being hired, friends must undergo a criminal background check and a driving record review as part of the verification process. After being hired, friends are trained in empathy, cultural competence, and humility.

Michael Walling, 22, who works as a friend of the pope near his home in Port Huron, Michigan, said most seniors are receptive to receiving help or having the opportunity to talk to someone during a couple of hours.

One of her clients has trouble walking, so Walling helps her vacuum and scrub the trailer and take her to the grocery store. On Christmas night, he even took her to lunch. “It was supposed to be my day off, but I didn’t want her to be alone on vacation,” she said.

Tim Barrage, a former parole officer who visits Bailey and a dozen other seniors in the Akron area each week, turned to Papa because he was looking for a flexible part-time job to supplement his business income. gun safety training.

“I’ve done work in the garden, hanging and disassembling Christmas decorations, cleaning ovens or stoves,” he said.

Every time he arrives at a member’s home, the pope tells him to check how the member is feeling and then periodically asks about issues that may include the wellness exam and health risk assessment. At the end of the visit, he informs the Pope about what services he offered and how the member interacted with him. He alerts his pope supervisors to a member’s possible health issues and Pope connects with the health plan to address them.

Jennifer Kivi, Medicare product development manager for Priority Health, a Michigan health plan, said members who have used the Pope service said it makes them feel less alone. “If we can reduce their loneliness, it will help members feel better and their physical health will improve,” he said.

The insurer doesn’t want her Pope friends to ask members a long list of health questions, but they can ask about cancer or diabetes exams, which can also boost a plan’s ratings. “What we’ve seen is that you can get a doctor to tell them and their insurance company to tell them they need it, but a friend of the pope can start building that relationship with them, and that means a lot more from them. “, he said.

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