Why an experiment in Massachusetts is using federal health money to pay for some very non-medical things.
By Rochelle Sharpe
BOSTON—Jim Chadwick listened with disbelief to the nurse and caseworker sitting in his living room. He had spent months battling suicidal thoughts, struggling to find solace from psychiatrists and drugs. Losing hope and frustrated by the health care system, he had stopped taking his medication. The anxiety was overwhelming, and he was unable to leave his home to buy food or get to the doctor.
But the health care workers were telling him that everything was about to change. He was being enrolled in a new pilot project, funded by Medicare and Medicaid, and his care would be a kind of experiment—one that would use federal and state money to cover not only his medical care, but also meals, transportation and almost anything else that could be construed as helping maintain his health. Even his toothpaste.
The idea behind the program, run by a Massachusetts nonprofit called the Commonwealth Care Alliance, is that the best way to treat a patient’s health problems sometimes means providing services that aren’t strictly health care. In the four years since those workers showed up at his door, Commonwealth Care has paid for Chadwick’s in-home therapy and his orthopedic shoes, and its workers have introduced him to an art community and accompanied him to a hearing to get his food stamps reinstated.
Chadwick can’t stop gushing about the results. He says he feels better than he has in years. Not only is his health stable, but he can actually leave his home. With the help of his caseworker, he reignited an interest in painting and now paints almost every day. He plans to display his work at an art gallery soon.
“They are the best by far,” said Chadwick, a slim, bald 65-year-old, whose eyes widen as his enthusiasm grows. “If it weren’t for them, I wouldn’t be here. This is my chance at life.”
If policymakers in Washington get on board and can make it work politically, there’s a chance that this experimental approach to Jim Chadwick’s life will reshape the future of Medicare for America’s elderly and disabled.
In the public-health world, it’s now conventional wisdom that health is connected to factors far beyond medicine—the result of things like stable housing, a good diet and social supports. What’s far less clear is how to pay for health care that runs on those principles. Most insurance programs—including Medicare, the nation’s largest—are built on the idea of paying doctors and hospitals for medical procedures, not funding preventive lifestyle improvements.
But the government has launched a joint Medicare-Medicaid initiative to test innovative health care models, with some states paying insurers a flat fee to care for patients, rather than paying fees for every medical service. Commonwealth Care, which has participated in two such demonstration projects, receives a fixed payment for each patient. Instead of paying for expensive hospital visits, the nonprofit has discovered that it’s far more effective to invest that money in preventive care. And because of the way its finances work, the healthier its patients, the more money the company makes.
The program could provide valuable lessons for the $700 billion Medicare system overall as it prepares for the aging of the baby boom generation, which will nearly double the population it covers over the next two decades. The Medicare trust fund that pays the hospital and doctor bills of most Americans over 65 is already approaching insolvency; current projections show it running out of money in 2026, which could force radical cuts in benefits if it doesn’t find a way to deliver more affordable care.
So far, only a handful of Medicare- and Medicaid-funded plans are running demonstration projects like the one for Chadwick. But starting next year, Medicare’s managed-care program, Medicare Advantage, will experiment with these ideas on a far larger scale, for the first time possibly covering some non-medical health-related services for patients, such as home-delivered meals. And as government moves away from the traditional “fee-for-service” system that reimburses doctors for appointments and procedures, and instead adopts payment models designed to reward providers for keeping patients healthy, the lessons Commonwealth Care has learned could provide the template for the Medicare program of the future.
The payoff could be huge. If the company’s template and cost reductions were replicated on a national scale, that could mean annual savings of billions of dollars.
But implementing Commonwealth Care’s system nationally could be daunting, given that it would require linking the reimbursement systems of two unwieldy bureaucracies, Medicare and Medicaid. Not only does any reform of Medicare move at a glacial pace, but since Medicaid is funded by the states, that kind of major change would provoke a dizzying number of political debates over who should pay for what.
Even if Commonwealth Care’s system can’t be completely cloned, there are still plenty of opportunities for federal savings. Every penny spent on social supports through Medicaid would save Medicare a dollar in medical expenses, the company estimates.
“Social supports are the key ingredient that can’t be ignored,” says Christopher D. Palmieri, Commonwealth Care’s president and chief executive officer. “If you don’t have heat, you’re probably not going to think about managing your diabetes.”
THE 15-YEAR-OLD company was founded by two public health veterans who had spent decades trying to improve the lot of the nation’s sickest patients. Commonwealth Care’s process is to focus first on caring for people’s basic needs, such as adequate food and housing, and then add in supports like transportation and housekeeping, depending on the patient. For people who feel isolated, it might mean paying for taxi rides to a community center. For those with chronic obstructive pulmonary disease, it might mean providing an air conditioner because hot weather can worsen their symptoms.
It’s a strategy backed by decades of research, which shows that strong social and physical environments are the foundations of good health. Some of its key tenets were developed by company co-founder Robert Master, a physician and innovative public health expert who demonstrated 40 years ago that home visits could reduce health care costs for the nation’s most vulnerable patients.
A former director of the state’s Medicaid program, Master wanted to reform health care ever since he was a teenager, according to published reports. He’d watched his ailing grandfather get substandard treatment for cancer because he was poor—a system he called “medical-care apartheid.” Over the years, he showed that low-income patients’ health could vastly improve if providers had the financial flexibility to address both their medical and social needs.
Commonwealth Care has maximized its flexibility to do just that. It not only cares for 30,000 of the state’s poorest and most disabled residents, but it insures them, too. It can cover unconventional benefits because of Massachusetts legislation that gives Medicaid providers wide leeway to determine what’s medically necessary for each patient. In Chadwick’s case, Commonwealth Care arranged for therapists to visit him at home, had caseworkers accompany him to medical appointments and helped him pay his bills.
The result: substantial cost savings and happier, healthier customers. Hospital admissions plunged 27 percent for the organization’s elderly clientele between 2011 and 2017, the company says. Thirty-day hospital readmission rates, meanwhile, declined 6.7 percent between 2015 and 2017 in its newer One Care program, which serves patients under 65. One Care, launched in 2013, also has soared in popularity, becoming the nation’s top-rated Medicare-Medicaid plan in 2016 and 2017, according to federal customer satisfaction surveys.
At Commonwealth Care, all this health and happiness translates into big money. Palmieri projects that by 2022, it will be saving Medicare and Medicaid about $100 million a year over what their costs for the same patients would have been in the traditional fee-for-service system. That’s a reduction of about 5 percent in health care costs for low-income elderly and disabled patients, coming at a time when overall health care costs continue to skyrocket.
THE KEY TO this kind of success lies inside people’s homes. That’s where caseworkers—called “care partners” in the Commonwealth Care system—really get to know their members and figure out everything they need to stay safe and healthy. “We see all the things we can solve to prevent catastrophic things from happening,” Palmieri says.
Nearly 500 of the company’s 1,100 employees make house calls.
As a case worker responsible for the well-being of 35 members, Harvard Thompson says he often discovers that patients neglect their health because of personal obligations. When one woman refused to go to a kidney dialysis center, he learned that she felt compelled to stay home to care for other family members. So the company arranged for in-home dialysis.
Trying to reduce unnecessary emergency room visits, Commonwealth Care partners with an ambulance company to send paramedics to members’ homes. “We create an emergency room experience in people’s living rooms,” Palmieri says, with paramedics visiting patients late into the night and giving them EKGs, IV fluids and antibiotics in their own kitchens or bedrooms. In an analysis of 2,300 paramedic visits since 2014, only 18 percent of patients who received a paramedic visit ended up needing hospital care, Palmieri says. In the U.S., “people don’t know how to use the outpatient health care system,” reflexively calling 911 when feeling sick and usually being told to go to the hospital.
Some company benefits may seem indulgent, like laundry services. But in fact, dirty sheets can lead to dire consequences, Thompson says, such as bed bug infestations. It can be especially dangerous for people with diabetes to get bug bites, since their disease makes them more susceptible to infections. When patients have bug infestations in their homes, the company pays for exterminators.
One patient, Keisha Greaves, a bubbly 32-year-old fashion designer with blue hair, says she was incredulous when she learned how Commonwealth Care would help her manage her muscular dystrophy, a progressive incurable disease that slowly robs victims of the ability to move. Among the benefits considered medically necessary: a motorized scooter, a house cleaner, meals, medication, acupuncture and massage therapy. “Medicaid didn’t offer half of what I needed,” says Greaves, who switched from regular Medicaid to Commonwealth Care, even though it meant she couldn’t keep her beloved primary care doctor.
Caseworkers also spend a lot of time helping members navigate the fragmented health care system. Sometimes, they go out of their way to help them deal with bureaucracy. One caseworker drove 50 miles to bring paperwork to a patient unexpectedly hospitalized, so the man wouldn’t lose a new apartment that would allow him to sleep in a bed, said Laura Black, the company’s vice president for care partnership and service delivery. The 400-pound man had been unable to fit through the bedroom door of his previous home, she said, and was forced to sleep in a chair.
Some patients don’t even know that the state assigned Commonwealth Care to be their health care provider, often because they don’t have a fixed address to receive mail. So, caseworkers try to track them down, sometimes finding homeless people by taping messages on telephone poles or under bridges.
The company tells dozens of heartwarming stories, but many challenges remain. It’s unclear how many people will ever be able to benefit from this kind of enhanced primary care, given difficulties of finding and enrolling so many expensive patients with complex needs. Commonwealth Care executives are trying to figure out how to expand the company, hoping that technology may help it serve more Massachusetts residents.
But even if the company’s model gets adopted more widely in the state, it’s hard to tell how many other states would be willing to spend as much money on Medicaid as Massachusetts does, or change their laws to provide a similar program. It’s also not clear whether Medicare would ever step in the way Medicaid does to pay for social supports that its middle-class patients might need. Plus, major changes to the program would likely need congressional approval, which would be politically fraught.
“If Medicare would use this model, we would end up with fewer people on Medicaid,” says Black, pointing out how many elderly people run out of money to pay for social supports and are forced into Medicaid.
Medicare Advantage is going to start giving a version of this approach a try, starting next year. As seniors wait to see what kinds of social supports Medicare Advantage will offer, Chadwick says he hopes Commonwealth Care will never go away.
He beams as he describes how Thompson helped him conquer his agoraphobia, once coming over to his house at 7:30 a.m. to take him to a favorite diner that he hadn’t visited in years. When he was having trouble finding the confidence to start painting again, Thompson suggested that he just mix paints together one day and doodle the next. Now, Chadwick has completed almost enough paintings for an exhibition.
“It feels good to have someone be on my side,” Chadwick says. “They help me with all my basic needs, and I do my part by being sober and honest.”
“This keeps me hopeful,” he says. “It makes me feel like I matter.”
Rochelle Sharpe is a freelance writer based in Boston.