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The Challenge of Providing Care to Complex Medicare Patients


Approximately 9 million Medicare beneficiaries are considered "complex care" and they often incur high out-of-pocket costs. As lifespans lengthen, it becomes important for Medicare to adapt to serve these complex care beneficiaries.

Approximately 9 million Medicare beneficiaries are considered “complex care.” These individuals often incur high out-of-pocket costs for Medicare-covered services as well as home ad community care not covered by Medicare.

A new issue brief from The Commonwealth Fund proposes a benefit option that would include home and community services. As lifespans lengthen, it becomes important for Medicare to adapt to serve these complex care beneficiaries.

“A new complex care benefit option for Medicare beneficiaries could improve patient and caregiver experience, help beneficiaries continue living at home, and reduce burdens on families who now try to patch together the resources needed to pay for care,” the authors of the issue brief wrote.

Complex care individuals are described as living at home or in the community—not long-term residents at a nursing, residential care, or assisted living facility—who have significant impairment in physical functioning and/or severe impairment in cognitive functioning. In 2010, the mean payment for complex-needs beneficiaries was $13,188, 129% more than the mean payment for noncomplex beneficiaries ($5754).

The complex care need benefit envisioned by the authors would target beneficiaries with physician or cognitive impairment as well as those who experience difficulty navigating multiple sources of acute care services. The backbone of this benefit would be a complex care organization (CCO), similar to an accountable care organization. The CCO would deliver a range of healthcare services, develop individualized care plans, provide care management services, coordinate all the care a patient receives, and ensure the care is both appropriate and high quality.

The benefit would cover nonmedical services that support independence and based cost sharing on the ability of the patient to pay. As such, larger subsidies would be provided to beneficiaries with low and moderate incomes.

“With more than 10,000 Americans turning 65 every day, the need for services to care for Medicare beneficiaries with complex needs will grow markedly over the coming decade,” the authors concluded. “Devising affordable, high-quality programs that can allow these individuals to remain at home both raises overall quality of life and potentially reduces spending on institutional care.”

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