Medicare Advantage Plans Send Pals to Seniors’ Homes for Companionship — And Profits


Widowed and normally dwelling alone, Gloria Bailey walks with a cane after two knee substitute surgical procedures and wishes assist with housekeeping.

So she was thrilled final summer season when her Medicare Benefit plan, SummaCare, started sending a employee to her home in Akron, Ohio, to mop flooring, clear dishes, and assist with pc issues. Some days, they might spend the two-hour weekly go to simply chatting at her kitchen desk. “I like it,” she mentioned of the free profit.

Bailey, 72, is one in every of 1000’s of seniors across the nation being visited every week by staff of Papa Inc. Often called “Papa buddies,” their major goal is to supply companionship to seniors together with serving to with errands and lightweight house responsibilities duties. Since 2020, greater than 65 Medicare Benefit plans nationwide have signed up with Papa, a Miami-based firm, to deal with members’ loneliness — an issue exacerbated by the pandemic.

“It’s the very best factor ever” to counteract social isolation, mentioned Anne Armao, a vp at SummaCare. Greater than 12% of the corporate’s 23,000 Ohio Medicare members used the Papa profit final yr.

However SummaCare and different well being plans additionally stand to profit by sending Papa buddies into members’ houses. The employees can assist the plans acquire more cash from Medicare by persuading members to get annual wellness exams, fill out private well being threat assessments, and bear lined well being screenings.

Conducting these steps helps plans in two methods:

  • By gleaning extra data, plans might uncover members have well being points which will earn greater reimbursement charges from Medicare.
  • Plans can enhance their star scores, that are primarily based on greater than 40 efficiency measures, together with most cancers, diabetes, and blood stress screenings; consequence measures reminiscent of controlling hypertension; and total satisfaction with the plan. Plans that rating not less than 4 stars on a five-star scale obtain bonuses from Medicare.

Bonus funds from the star scores make up an growing share of federal funds to those personal Medicare Benefit plans, that are a substitute for conventional Medicare. In 2021, Medicare paid plans $11.6 billion in bonus pay, double the quantity in 2017.

The federal authorities’s base pay for the plans is a month-to-month price for every member, however it will increase that quantity primarily based on the members’ well being dangers. So plans additionally get billions of {dollars} a yr in additional funds by pinpointing members’ well being issues by way of quite a lot of measures, together with the well being threat assessments.

But federal investigators have discovered these diagnoses don’t all the time lead to additional treatment or follow-up care to beneficiaries. Because of this, the federal authorities might be overpaying the Medicare well being plans and losing billions in taxpayer {dollars}, based on the Medicare Fee Advisory Fee that advises Congress.

In a report final September, the Well being and Human Providers inspector normal discovered 20 Medicare Benefit corporations generated $5 billion in extra payments from the federal authorities for diagnoses recognized by way of well being threat assessments and chart critiques with out documentation that the sufferers had been handled for these points.

Practically half of Medicare enrollees get their protection by way of Medicare Benefit.

David Lipschutz, affiliate director of the Middle for Medicare Advocacy, mentioned Papa buddies present an necessary profit to seniors by serving to them with chores, decreasing their loneliness, and getting them to medical appointments. However the profit also can assist the insurers’ backside traces.

“If there may be one factor these plans are good at is maximizing their revenue,” he mentioned.

Medicare Benefit plans usually give docs monetary incentives to get sufferers to bear well being assessments. Plan staff repeatedly name sufferers with provides to ship nurses or docs to their houses to finish them. Lipschutz mentioned well being threat assessments are helpful provided that the well being plans act on the data by ensuring sufferers are getting therapy for these points.

Armao mentioned the well being threat evaluation and annual wellness examination reminders are on the listing of issues Papa staff are instructed to ask about on visits.

“They’re our eyes and ears who can be taught a lot from members of their houses,” she defined. Buddies look in fridges to see if members have sufficient to eat, examine on how members are feeling, and remind them to take prescriptions. SummaCare even directs buddies to ask whether or not members have urinary incontinence or are updated on most cancers screenings.

Andrew Parker, who based Papa in 2017 after discovering a few school college students to go to along with his grandfather, take him to physician appointments, and do different errands, mentioned he estimates his firm will present greater than 1,000,000 hours of companionship in 2022. The Medicare plans pay Papa, a for-profit firm, a per-member price month-to-month.

“Papas [pals] are very proactive and can name you to see how you’re feeling and, possibly not on the primary day however over the course of this system, can ask, ‘Do you know your well being plan would favor when you had a wellness examination and it might make it easier to along with your well being?’” he mentioned. “A pal is a trusted adviser who can get them to consider advantages they have no idea about.”

He mentioned insurers usually don’t know a member is going through a well being difficulty till they see a medical declare. “We will establish issues they don’t learn about,” he mentioned.

Till lately, Medicare hardly ever paid for non-health companies. However Papa started working with Medicare Benefit plans in 2020, only one yr after this system started permitting the personal insurers to have extra flexibility addressing members’ so-called social needs, reminiscent of transportation, housing, and meals, which aren’t usually lined by Medicare however might affect well being. Papa’s objective of addressing members’ loneliness took on much more significance throughout the pandemic when many seniors turned socially remoted as they sought to scale back their threat of getting contaminated.

Papa has greater than 25,000 buddies whose common age is mid-30s. Earlier than being employed, buddies should bear a legal background examine and a driving file overview as a part of the vetting course of. After being employed, buddies are skilled on empathy, cultural competency, and humility.

Michael Walling, 22, who works as a Papa pal close to his house in Port Huron, Michigan, mentioned most seniors are receptive to getting assist or an opportunity to speak to somebody for a few hours.

Certainly one of his shoppers has bother strolling so Walling helps vacuum and mop her trailer and take her to the grocery retailer. On Christmas Eve, he even took her out to lunch. “It was to be my time off, however I didn’t need her to be alone on the vacation,” he mentioned.

Tim Barrage, a former parole officer, who visits Bailey and a couple of dozen different seniors within the Akron space every week, turned to Papa as a result of he was on the lookout for a versatile part-time job to complement revenue from his firearms security coaching companies.

“I’ve carried out work within the backyard, hanging up and taking down Christmas decorations, cleansing ovens or stovetops,” he mentioned.

Every time he arrives at a member’s house, Papa directs him to examine to see how the member is feeling total after which periodically ask about points that may embody the wellness examination and well being threat evaluation. On the finish of the go to, he reviews to Papa about what companies he offered and the way the member interacted with him. He alerts his supervisors at Papa to a member’s potential well being points, and Papa connects with the well being plan to deal with them.

Jennifer Kivi, supervisor of Medicare product growth for Precedence Well being, a Michigan well being plan, mentioned members who’ve used the Papa service mentioned it makes them really feel much less lonely. “If we are able to cut back their loneliness, it helps members really feel higher and their bodily well being will enhance,” she mentioned.

The insurer doesn’t need its Papa buddies to ask members a protracted listing of well being questions, however they will ask about most cancers or diabetes screenings, which can also bolster a plan’s scores. “What we’ve got seen is you’ll be able to have a physician inform them and their insurance coverage firm inform them they want it, however a Papa pal can begin to construct that relationship with them, and it means much more coming from them,” she mentioned.

This story was produced by KHN (Kaiser Well being Information), a nationwide newsroom that produces in-depth journalism about well being points. Along with Coverage Evaluation and Polling, KHN is without doubt one of the three main working applications at KFF (Kaiser Household Basis). KFF is an endowed nonprofit group offering data on well being points to the nation.

KHN (Kaiser Well being Information) is a nationwide newsroom that produces in-depth journalism about well being points. Along with Coverage Evaluation and Polling, KHN is without doubt one of the three main working applications at KFF (Kaiser Household Basis). KFF is an endowed nonprofit group offering data on well being points to the nation.

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