On Tuesday, October 19, HC3 hosted a conversation exploring the possible outcomes of expanding Medicare coverage to include dental, vision, and hearing benefits as part of the $3.5 trillion budget reconciliation bill. The move, as proposed by House and Senate Democrats as part of the $3.5 trillion budget reconciliation bill, would be the biggest expansion of Medicare since Congress added a drug benefit in 2003 and would go a long way toward improving the health and well-being of millions of older adults.
Jason Montrie, President, Pareto Intelligence
Tricia Neuman, Senior Vice President & Director, Program on Medicare Policy, Kaiser Foundation
Soujanya (Chinni) Pulluru MD, Senior Director II, Clinical Transformation, Innovation, and Operations, Walmart Health
Marko Vujicic, PhD, Chief Economist and Vice President, American Dental Association
Moderator David Smith, Founder and CEO, Third Horizon Strategies, Co-Founder, Health Care Council of Chicago
Watch the Recap | Link to Video
Presented Slide Deck 10.19.2021
Summary of Overview: Medicare Landscape
Cost barriers are the most severe for dental care, above primary medical care,
behavioral/mental health care and eye care access. Approximately one in six older adults in the U.S., Australia, Canada, New Zealand reported skipping a dental visit because of the cost. In 2019, 47 percent of Medicare beneficiaries did not have any dental coverage, and even those with coverage often do not have comprehensive coverage. Sixty-eight percent of Black beneficiaries and 61 percent of Hispanic beneficiaries did not visit the dentist.
Coverage is good for preventive services but has high costs and caps for other services. In 2018, out-of-pocket spending for dental and hearing care was $874 and $914, respectively.
Data shows that, in 2021, Medicare Advantage (MA) enrollees do have access to some benefits not covered by traditional Medicare. Between 94 and 99 percent of individual MA plans cover dental, hearing, and eye care. Out-of-pocket costs are lower for people with MA plans compared to traditional Medicare, but the difference is not as significant as one would expect. There is not much of a difference between beneficiaries that cannot afford dental, vision, hearing care in MA plans versus traditional Medicare. However, there is a significant difference amongst races.
Huge investments have been made into private MA plans that have been coordinating more dental, vision, hearing, and over-the-counter medications. The top expanded supplemental benefits between 2018-2020 were: telehealth, transportation, meals, nutrition/wellness, home modifications, in-home support services, and acupuncture. Expansion of dental, hearing, and vision could potentially take funding away from other important benefits.
As providers look at the expansion of access to care, there is a strong emphasis on these needed benefits, but there are a lot of details beneath the surface around funding. The Congressional Budget Office (CBO) CBO estimated that dental, vision, hearing benefits would cost ~$358 billion over 10 years. These benefits would contribute directly to the Medicare insolvency trust fund.
Specific barriers such as dental access ultimately overwhelms the pricing. One in five Americans have hearing issues, which, left untreated, can lead to higher risks of other health issues, including mental health challenges, dementia, falls, etc. Data that shows these correlations will be key in understanding what is most beneficial to enhance benefits and where it can have the most relevant impact. Most providers are supportive of expansions, but, according to Dr. Pulluru from Walmart Health, the “devil is in the details” as there are issues that still need to be ironed out.
D: There is an integral connection between oral health and other health outcomes. Can we expect or anticipate these benefits to have a positive impact on costs of other Medicare benefits?
M: More research is needed on this, but it seems likely that there will be fiscal offsets. People with diabetes who have uncontrolled inflammation or gum disease, have higher health care costs than diabetics who is managing their oral health care.
D: Is there anything the CBO could end up doing that would make the fiscal path of this more palpable?
T: The CBO has not scored the current version because the current version is changing daily. The CBO is tough when it comes to offsets. The other benefits would have to be pretty solid for that to happen.
D: What is your take on the legislation overall? I would also be interested if analysis has been run on claims data and how those look for those that have the dental benefit compared to those that don't.
J: Private companies have been making huge investments in over-the-counter programs for dental, vision, and hearing, but one of the more exciting things is that these new programs are creating opportunities to address issues such as transportation, social isolation, food, etc. It is encouraging to see investment in programs like these, that no one would have been interested in five years ago. There is now a clear understanding as to why these benefits are important to these programs. The concern remains around whether these same benefits will be included in the benchmark, and whether or not there will be spending for them. There’s still work to be done in terms of figuring out the funding.
T: This is really tough for Congress to navigate. When congress adds benefits for traditional Medicare, it increases costs for MA plans. The industry is very concerned about any kind of adjustment that would affect their payments. The industry has been effective in making the case that these benefits are very important and the benchmark should be adjusted - but this will affect costs for those who are already covered in MA plans. The industry is concerned about any kind of adjustment that would affect their payments at a time when solvency issues need to be addressed. It would be helpful to learn from MA plans because they have experience and claims data that could inform these conversations.
D: Do you have enough data from your clinics about outcomes for individuals that can’t access dental, hearing or vision, and those that can?
C: It is still too early to tell because we are just beginning to enter the value-based care space with the ability to take on risk. But if you think about it, hearing loss is associated with higher health care spending. I’m sure if you looked at the claims data, you would find that these benefits would lower overall health care costs.
J: We found that individuals using over-the-counter benefits performed better than other cohorts. Better numbers around ED visits, better spending, less falls, and so on. That particular benefit had an outsized impact. We recently looked at a large, underserved population and found that one-third of the population had a food, transportation, or housing situation, as an identified gap. As an industry, we are just beginning to see how uncovering this data and designing programs to address these issues can have an impact.
C: If dental care was paid for universally, people would find a way to provide access to those who don’t have it. What we often miss is that there is a supply and demand component that reduces health inequity. Once you start to pay for things a certain way or investing in a certain population, it incentivizes people to set up shop in those communities. It becomes an economically sustainable opportunity.
D: On the supply side for dentists, how are they thinking about this legislation? If it passed, what would be the uptake?
M: It all depends on the reimbursement structure, administrative burden, and so on. If it follows the Medicare paradigm of paying more than Medicaid but less than private, you are going to have a broad spectrum of dentists. The top barrier for people is that they cannot afford it, not that they cannot find a provider. Legislation alone may not address geographic shortages. Ideally, the program would be set up to help the most vulnerable populations, but the program is not currently set up that way.
D: Do you think a lower price tag would be a better strategic tactic or do we just go big or go home?
T: Medicare has been a pretty successful program in terms of physician access, so it could potentially happen amongst dentists as well. In terms of scaling the benefits, I think there could be a strong pullback from Democrats because Medicare is a social benefit. There may be some ways to scale back the benefit, but whatever is done needs to be done well. Some people have proposed focusing on preventive care, others propose hiring premiums, but we really don’t know what the best path is, and it may take some time. Ultimately, it would be a disaster to create a new benefit and not have it work.
D: How does including these benefits in part B potentially impact the Medicare Advantage and Medicaid markets?
J: There is a lot of intersection between Medicare and Medicaid. It’s hard to think about one without thinking about the other. There is a lot to look at from the past 15-20 years for the ability to enhance and pay for benefits.
D: Would this drive people towards traditional and out of MA? C: People with MA are typically very happy and feel better taken care of. So, I don’t foresee us moving back on that.
D: Assuming this legislation goes through as currently proposed. Fast forward five years, what is one good thing and one unexpected thing that happened? C: More seniors are receiving quality care and access to care. There will probably be a lot of cropping of institutions that might take advantage of a newly funded system.
J: We recognize how integral these benefits are to health, hoping that the benefits do not take funding away from other benefits.
T: Agree with others, with the caveat that some people may still not be able to afford it. We can expect some progress, but ultimately may not end up much different from where we are now.
M: We will begin to break down siloes between these three services and primary care. Under incentivized prevention, we will need a new payment model to completely reform.