Forward, Not Back: We Helped Draft 10 Recommendations to Improve Medicare in California

We are facing a crucial moment for the 6.6 million Californians enrolled in Medicare, the federal government’s health insurance for people older than 65.

With Congress in the middle of a debate over potentially sweeping changes to the federal budget, the future of this cornerstone program for protecting Americans as we age remains unclear. Significant cutbacks are possible, and the same is also true for Medicaid, the shared federal and state program that helps cover medical costs for millions of people with limited income and resources. At Archstone Foundation, however, our mission remains steady: improve the programs and policies that lead to better care for older Californians.

To that end, the Foundation was proud to be part of the California Medicare Collaborative, a recently concluded effort to develop recommendations for improving how Medicare works in our state. Partners included the PBGH California Quality Collaborative, The SCAN Foundation, West Health, and the CA Department of Health Care Services Office of Medicare Innovation and Integration.

After a full year of convening, deliberation, and consensus-building, we are delighted to report the top 10 ways we believe the program can be improved for the benefit of its beneficiaries.

• Strengthen chronic care management. Medicare beneficiaries lack support because of workforce shortages, misaligned payment policies, and a lack of actionable data. Their care management would be improved by creating such supportive funding as state-enforced primary care investments goals, scaling and aligning Medicare Advantage value-based contracts, and identifying how providers can best use Medicare fee-for-service codes to receive reimbursement for efforts to manage chronic conditions.
• Promote advanced primary care. Advanced primary medicine focuses on prevention and chronic condition management by using team-based, integrated, accessible, equitable, and data-driven care. Ways to promote this approach with Medicare patients include health plan or philanthropy-funded training for providers, aligned value-based payment models in Medicare Advantage plans that incentivize the approach, and support that urges providers to adopt related technologies, including remote patient monitoring and population health management tools.
• Increase support for addressing health related social needs. Those needs have an impact on our well-being but are not well addressed by the current healthcare system. Community-based organizations can help, but Medicare-funded models integrating health care and community-based services are in their infancy. This would be improved by increasing provider participation in programs (such as ACO REACH) that incentivize coordination with CBOs, using value-based incentive design and the special supplemental benefits of Medicare Advantage plans to fund CBOs, and designating champions within health care organizations to lead CBO partnerships.
• Improve population health management. Promoting equity and reducing health disparities is difficult without comprehensive and accurate data on beneficiaries’ demographics and health related social needs. As of 2019, there was complete information on only 40 percent of their races and less than 20 percent of their ethnicities. In addition to collecting better information at the point of care, the exchange of records should be enhanced to reduce duplication of effort and broaden access to the best data. Government, philanthropy, and Medicare Advantage plans can support this by funding technical assistance. In addition, new reporting to the Centers for Medicare & Medicaid Services on utilization of supplemental benefits would help uncover which of those benefits do the most to address health related social needs.
• Expand access to care for special populations. Beneficiaries with low incomes, in rural areas, with limited English proficiency, and on Medicare because of Social Security disability face special barriers. These can be lowered by testing and then scaling effective methods for easing their access to care such as telehealth visits, home visits, more use of community health workers, and increasing the number of bilingual providers.
• Grow the workforce to equitably serve beneficiaries. California has a shortage of workers in primary care, behavioral health, and geriatrics. And its clinical workforce does not reflect the state’s racial, ethnic, or language diversity – despite evidence that outcomes improve when caregivers share the backgrounds of their patients. To improve things in the short term, geriatric psychiatry residents should be fast-tracked to places with the greatest needs, spending should increase on programs for students from underrepresented communities who want enter fields with shortages, the current workforce should receive more training in geriatrics and cultural competence, and community health workers should be better integrated into teams caring for older adults.
• Help beneficiaries make informed choices. Market complexity and lack of transparency make it difficult for beneficiaries and their caregivers to sign up for the best coverage. This would be improved by expanding the well-regarded Health Insurance Counseling and Advocacy Program (HICAP), which serves only a small fraction of Californians, by doing more to promote the use of the Medicare Plan Finder comparison tool and by distributing more neutral information about coverage options through the media and trusted community partners.
• Normalize seeking cognitive and behavioral health services. Many beneficiaries hesitate to ask for such help because of social or cultural stigma. Providers and health plans can change this by including information on how to access services in patient materials and collaborating with community organizations to develop and share culturally appropriate messages. The state government and its partners could launch a communications campaign to reduce stigma and raise awareness of available resources
• Promote better detection of cognitive health needs. Primary care providers often lack training and workflows to screen beneficiaries for cognitive decline or behavioral challenges and then refer them to specialists. Doctors caring for beneficiaries need to improve and expand their ability to diagnose dementia by taking training from organizations including Dementia Care Aware; signing up for continuing education classes on cognitive and behavioral health; making the most of their patients’ annual wellness visits; and expanding screenings for social needs that impact cognitive and behavioral health.
• Increase support for those with cognitive health needs. Beneficiaries with complex cognitive and behavioral health needs often experience fragmented care, leading to poor outcomes and high system utilization. Caregivers also face significant burdens. To improve this, providers and health plans can do more to solicit feedback from patients and families about their experiences and needs, pilot new care models for navigation and peer support, and promote regional implementation of the federal Guiding an Improved Dementia Experience (GUIDE) Model.

Learn more about the California Medicare Collaborative recommendations here.