Medicare Advantage plans send friends to nursing homes for companionship and benefits

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Widowed and mostly living alone, Gloria Bailey walks with a cane after two knee replacement surgeries and needs help with the housework.

So she was thrilled last summer when her Medicare Advantage plan, SummaCare, began sending a worker to her home in Akron, Ohio, to mop floors, clean dishes and help with computer problems. Some days they spent the weekly two-hour visit chatting at his kitchen table. “I love it,” she said of the free perk.

Bailey, 72, is one of thousands of seniors across the country visited weekly by employees of Papa Inc. Known as “Papa Pals”, their main goal is to provide companionship to seniors while helping them run errands and do light household chores. Since 2020, more than 65 Medicare Advantage plans nationwide have enrolled with Papa, a Miami-based company, to address member loneliness — a problem exacerbated by the pandemic.

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

But SummaCare and other health plans also stand to gain by sending Papa friends to members’ homes. Workers can help plans raise more money from Medicare by persuading members to take annual wellness exams, complete personal health risk assessments, and undergo covered health exams.

Completing these steps helps plans in two ways:

  • By gleaning more information, plans can discover that members have health conditions that can earn higher Medicare reimbursement rates.
  • Plans can increase their star rating, which is based on more than 40 performance metrics, including cancer, diabetes, and blood pressure screenings; outcome measures such as hypertension control; and overall satisfaction with the plan. Plans that score at least four stars on a five-star scale receive bonuses from Medicare.

Star rating bonus payments represent a growing share of federal payments to these private Medicare Advantage plans, which are an alternative to traditional health insurance. In 2021, Medicare paid plans $11.6 billion in bonuses, double the amount in 2017.

The federal government’s base salary for the plans is a monthly contribution for each member, but it increases this amount based on the members’ health risks. So plans also receive billions of dollars a year in additional payments by identifying member health issues through a variety of measures, including health risk assessments.

Yet federal investigators have found that these diagnoses do not always result in additional treatment or follow-up care for recipients. As a result, the federal government is likely overpaying Medicare health plans and wasting billions of taxpayer dollars, according to the Medicare Payment Advisory Commission that advises 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 payments from the federal government for diagnoses identified by risk assessments for health and chart reviews without documentation that patients had been treated for these conditions.

Nearly half of Medicare enrollees get their coverage through Medicare Advantage.

David Lipschutz, associate director of the Center for Medicare Advocacy, said dads provide a significant benefit to seniors by helping them with household chores, reducing loneliness and getting them to medical appointments. But the benefit can also help insurers’ bottom line.

“If there’s one thing these plans are good at, it’s maximizing their profit,” he said.

Medicare Advantage plans often offer doctors financial incentives to get patients to undergo health assessments. Scheme agents repeatedly call patients to offer to send nurses or doctors to their homes to supplement them. Lipschutz said health risk assessments are only useful if health plans act on the information by ensuring patients receive treatment for these conditions.

Armao said health risk assessments and annual wellness exam reminders were on the list of things Papa employees should ask for during visits.

“It’s our eyes and ears that can learn so much from the members back home,” she explained. Buddies check refrigerators to see if members have enough to eat, check on how members are feeling, and remind them to pick up their prescriptions. SummaCare even asks friends to ask if members have urinary incontinence or are up to date on cancer screenings.

Andrew Parker, who founded Papa in 2017 after finding a few college students to visit his grandfather, take him to the doctor and run other errands, said he believes his business will provide more than one million hours of companionship in 2022. Health insurance plans pay Papa, a for-profit company, a monthly fee per member.

“Dads [pals] are very proactive and will call you to find out how you are feeling and, perhaps not on the first day, but during the program, may ask you, “Did you know that your health plan would prefer you to have a wellness exam? be and could help you with your health? “, he said. “A buddy is a trusted advisor who can get them thinking about benefits they don’t know about.”

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

Until recently, Medicare rarely paid for non-medical services. But Papa began working with Medicare Advantage plans in 2020, just a year after the program began allowing private insurers more flexibility to meet members’ so-called social needs, such as transportation, housing and food, which are generally not covered by Medicare but could influence health. Papa’s goal of tackling limb loneliness took on even greater significance during the pandemic when many seniors became socially isolated as they sought to reduce their risk of infection.

Dad has over 25,000 buddies whose average age is around 30. Before being hired, buddies must undergo a criminal background check and a driving record review as part of the vetting process. After being hired, buddies are trained in empathy, cultural competence, and humility.

Michael Walling, 22, who works as a dad near his home in Port Huron, Michigan, said most seniors are receptive to getting help or talking to someone for a few hours.

One of his clients has trouble walking, so Walling helps him vacuum and clean his trailer and take him to the grocery store. On Christmas Eve, 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,” he said.

Tim Barrage, a former parole officer, who visits Bailey and a dozen other Akron-area seniors weekly, turned to Dad because he was looking for a flexible part-time job. to supplement income from his gun safety training businesses.

“I worked in the garden, hung up and taken down Christmas decorations, cleaned ovens or hobs,” he said.

Each time he arrives at a member’s home, Dad asks him to check in on how the member is feeling overall and then periodically ask about issues which may include the wellness check and the health risk assessment. At the end of the visit, he reports back to Dad on the services he provided and how the member interacted with him. He alerts his supervisors at Papa to a member’s potential health issues, and Papa connects with the health plan to address them.

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

The insurer doesn’t want its Papa buddies asking members a long list of health questions, but they may ask about cancer or diabetes screenings, which can also boost a plan’s ratings. “What we’ve seen is you can have a doctor tell them and their insurance company tell them they need it, but a dad can start building that relationship with them, and it means a lot more coming from them,” she said.

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