C-TAC recently submitted comments to the National Academies on their request for information regarding federal policies that contribute to racial and ethnic health inequities and did so from the perspective of those living with serious illness. Here are the policies we identified and some of our proposed solutions:
Advance care planning (ACP) patient cost sharing – C-TAC has historically supported improving access to ACP, however one aspect that creates inequity is that the CPT billing codes for advance care planning include a 20% patient cost-sharing (copay/deductible) when done any time outside of an Annual Wellness Visit. This cost-sharing is a health equity issue as it disproportionately affects Black and Hispanic communities. C-TAC tried to have Medicare remove the cost-sharing, but they lacked statutory authority to do so, We therefore just worked with Senators Warner and Collins and Representative Blumenauer to introduce legislation to remove the ACP cost-sharing instead.
The Medicare Hospice Benefit (MHB)- Hospice usage is much lower among communities of color perhaps due to the fundamental inequities built into the MHB. Hospice was designed to be mostly delivered in the person’s home, which presumes both the dying person has a physical home, and also someone to provide care for them there. Families from under-resourced communities often cannot undertake this due to tenuous or multiple jobs where they lack paid time off or cannot telework. Current hospice policy also requires people to forego disease-modifying treatment, something that is hard to ask of communities that have never gotten adequate health care in the first place. The requirement of a six-month prognosis can be difficult for those who may be diagnosed only in the last stage of illness when they have days or weeks, instead of months, left to live. One solution would be to allow those on hospice to also access disease-modifying treatment. C-TAC hopes that the current Medicare Advantage Value-based Insurance Design, MA VBID, will provide more data on this and the benefits of hospice for the MA population. Data from private payers also shows that allowing and paying for concurrent is cost-efficient and allows people to have hospice for longer.
Allowing Medicare to address social needs- Community-based organizations (CBOs) offer aid like spiritual care, housing support, transportation, and healthy meals that ensure that medical care is most effective. However, their services are not covered by Medicare and they often lack the infrastructure–sustainable financing models, IT, and workforce- to support the serious illness population in their community. We, therefore, recommended providing resources and support to CBOs to participate in healthcare programs and procurement processes, having healthcare providers consistently assess patients and their family caregivers for social risk factors and requiring them to make appropriate referrals to CBO services, and, ultimately, reforming statute and finance structures to enable CBOs to be funded through Medicare reforms.
Value-based Contracting- While this is a better way to promote good care and value than fee-for-service payment, can be difficult to participate for providers from under-resourced communities. C-TAC, therefore, supported providing upfront investment via advance shared savings payments and/or a health equity payment adjustment to help those providers in under-resourced communities invest in the necessary IT systems to track performance and the reporting mechanisms for such contracting.
