Proposed legislation is gaining traction on Capitol Hill that would allow states to create Accountable Care Organizations (ACOs) for seniors in continuing care retirement communities (CCRCs) with existing Medicare and Medicaid coverage.
Congressmen Joe Barton (R-Tex.) and Ralph Hall (R-Tex.) recently signed on as cosponsors of the proposed bill, HR 2376 or the Medicare Residential Care Coordination Act, introduced in 2013.
The bill, written by Congressman Michael Fitzpatrick (R-Pa.), will allow up to five states to create and implement new models which feature lifetime health and housing benefits for eligible CCRC residents. The Centers for Medicare & Medicaid Services (CMS) would have the authority to select participants in the pilot program from the states that apply.
In other ACO models, such as the Pioneer ACO program, the jury on ACOs’ benefits is still out. Ten medical institutions of the original 32 that participated in the program left in favor of other Medicare saving opportunities or dropped out of the ACO program all together.
Meanwhile, some senior living providers across senior housing products are strategizing to establish themselves as partners in ACOs.
Proponents of the bill say it would be a boon for CCRC providers, their residents and the Medicare and Medicaid programs.
The potential impact
HR 2376 would enable new models like WELShift, a program that has been in development for several years, to be realized. WELShift ensures lifetime housing and healthcare security for seniors in CCRC settings, Jeff Petty, president and CEO of Philadelphia, Pa.-based Wesley Enhanced Living and architect of WELShift, tells SHN.
The bill would lower the total cost of care for seniors by providing on-site care coordination and disease management services to avoid hospitalizations, proponents say. An interdisciplinary health care team, led by salaried primary care physicians, would integrate comprehensive primary and post-acute health care services and coordinate acute and specialist care.
Under the proposed bill, eligible CCRC residents would need to be enrolled in Medicare Part A and B; reside in a participating CCRC; and can be, but do not have to be, dual-eligible. The bill also expands the definition of dual eligible to allow coordination of Medicare and Medicaid services.
“This guarantees that all participating residents can continue to reside in their CCRC/home regardless of their ability to pay, and the state will not incur the expense of a Medicaid nursing home for these CCRC residents,” Petty says, adding that WELShift has projected savings of 30% for Medicare and 30 to 35% for Medicaid.
With the expansion of the Medicaid program contemplated by WELShift, more middle-class people would receive services when needed rather than after it is too late, he says.
“Typically CCRCs are limited to upper-middle class or above clients,” Petty says, noting that WELShift is a model for the middle class.
For many CCRC residents, what could have been prevented by a routine trip to the doctor’s turns into a trip to the emergency room, he adds.
“There are so many times that if a doctor was physically present in the community he or she could take care of whatever is ailing that residents — studies have shown that more than 60% of hospitalizations were potentially avoidable nationwide,” he says. “But now, if Mrs. Smith has symptoms at 11 p.m. and can’t get her doctor on the phone she’ll be told to come into the ER so a doctor was see her. Or, her doctor hasn’t seen her in 20 or 30 days and has no clue what’s going on.”
The bill is also attracting the attention of providers in states outside of Pennsylvania.
A third Texas representative may sign on soon, and providers who support the bill are continuing to meet with legislators to garner support, says Ron Jennette, president and CEO of nonprofit CCRC provider Methodist Retirement Communities, based in The Woodlands.
Models like WELShift make sense to Jennette, who says it would allow for a continuum of care not now seen in CCRCs.
“It breaks down the silos [between senior living products],” Jennette says, noting that having on-site medical care for independent living residents, who currently must travel off campus to receive medical care, will help CCRCs assist residents in staying as healthy as possible.
“[In the WELShift model] medical people would be watching residents from day one in independent living to help them stay as healthy as possible,” he says. “Medical staff would be roaming the campus with residents. Sometimes, our housekeepers will realize this person has started doing something a little different, but there’s no doctor or nurse on staff to tell that to in independent living.”
But the bill’s survival depends on lawmakers’ and CCRC providers’ understanding of how it works, both Jennette and Petty agree.
“Our process has been one of mostly education,” Petty says. “It’s been a struggle. A lot of [lawmakers] don’t know what a CCRC is.”
Written by Cassandra Dowell