This past December after eight months of formal work the Senate Finance Committee’s “Bipartisan Chronic Care Working Group” released for comment a 30-page memo outlining 23 policy options to improve chronic care quality, patient outcomes and cost efficiency. While the Committee is not endorsing any of the options identified members will likely not stray far from this list when they move to drafting legislative language next month at least in part because members insist the bill must be cost neutral. Committee members and staff should be applauded for their effort to date since both political parties have been disinterested in adding policies to improve the Medicare program. (Last year’s MACRA bill was largely unpaid for and aptly described by Henry Aaron in the New England Journal of Medicine as a log rolling exercise.) On balance, the Committee’s effort should leave Medicare stakeholders cautiously hopeful. While some of the proposed options are obvious and incrementally beneficial, others might aid in innovating care delivery and in advancing CMS’s efforts to improve quality and value payment.
Several proposed options are obvious in that they are long over due. The Committee proposes generally to improve the integration of care for individuals with a chronic disease combined with a behavioral health disorder. This proposal, possibly more than any other, could not be more welcomed. Behavioral health disorders in combination or not with chronic disease or another chronic disease are vastly under-diagnosed and under-treated. The Committee would be well served if members explored lifting billing restrictions that prohibit qualified non-physicians from treating beneficiaries with behavioral conditions. For example, there are limitations on clinical psychologists, clinical social workers and medical family therapists who are qualified but excluded from billing under the new chronic care management (CCM) code, evaluation and management codes and Health Behavior Assessment and Intervention codes. This is particularly problematic when you consider both the prevalence of behavioral health disorders and the shortage of trained behavioral health professionals.
The Committee proposes to expand telehealth services in four ways: waiving the originating site requirement for at risk ACOs; permitting MA plans to include telehealth in their annual bid amount; and, expanding its use to encourage home hemodialysis and the more timely diagnosis of stroke. The option concerning ACOs does not go far enough. There is substantial Medicaid, Veteran’s Administration, Indian Health Service and commercial plan evidence, despite the Congressional Budget Office’s (CBO’s) contrary view, telehealth and remote monitoring services are cost efficient. Also, this proposal as currently conceived would only help five percent of ACOs, or the 22 out of 434 that are currently in an at risk track. MA plans, for example Humana, have already begun using telehealth services formally or not just through the use of any rebate dollars. Regardless, adding telehealth services to MA coverage will only add to the already considerable number of ACO program disadvantages compared to MA. (As a related aside, the inequity between these two programs certainly helps explain why providers are fleeing to MA. Nearly 60 percent of 2016 MA plan growth is attributable to provider or PSO plans.) Allowing home hemodialysis patients to receive their monthly clinical visit via telehealth would, as the Committee notes, encourage more than the 10 percent of ESRD patients that currently receive dialysis at home. The policy would also improve patient independence, quality of life and reduce beneficiary exposure to iatrogenic harm. Expanding the use of telehealth to treat stoke cannot be more welcomed particularly when you consider the woefully low rates, at less than five percent, of tPA administration to treat ischemic stroke and the profound racial disparities in stroke care.
Two Committee options concern beneficiary out of pocket expenses. Both are welcomed. The Committee proposes to waive the current $8 CCM copay and allow at risk ACOs the option to waive beneficiary cost sharing. The CCM copay has been widely criticized and partially explains the slow uptake to date in provider use of the CCM code. While helpful, the option to waive some or all of an at risk ACO beneficiary’s cost sharing, again, does not go far enough. Considering the substantial problem of unstable assignment in the ACO program, offering copay waivers help insure beneficiaries remain assigned since they would more routinely seek care without having to decide whether care is essential or not and/or avoid higher intensity care particularly for beneficiaries who cannot afford first dollar Medigap coverage. This is the least the Committee can do.
ACO and MA Policy Options
There are five policy options concerning the ACO and MA programs that should be considered in relation to one another since these two programs interact or compete. The Committee proposes to “clarify” an ACO’s ability to offer social and transportation services without reimbursement. The Committee also proposes to expand the number of MA supplemental benefits to improve chronic care treatment. Considered in tandem once again ACOs are left disadvantaged. For ACOs innovation becomes at best an upfront expense while for MA plans, rebate dollars could be used to provide care from an expanded list, of an already extensive number, of supplemental benefits.
The Committee is considering allowing all individuals with ESRD the option of enrolling in an MA plan and requiring MA plans to offer the hospice Part A benefit. Currently individuals under 65 with ESRD are ineligible to enroll in MA with two exceptions and beneficiaries in Medicare fee for service (FFS) that are subsequently diagnosed with ESRD cannot enroll. Concerning hospice, the Committee is likely following MedPAC’s 2014 recommendation. Including hospice in MA, MedPAC argued, would promote integrated, coordinated care and make it more feasible for plans to offer concurrent curative and palliative care. How specifically ESRD and hospice care is integrated or further integrated in MA is important. For example, hospice access, beneficiary costs and quality under MA should at least comparable to fee for service hospice care. This point aside, since ACOs already offer ESRD and hospice care to all Medicare beneficiaries so too should MA plans.
Lastly, the Committee is proposing to give Track 1 ACOs the choice of whether their beneficiaries be assigned prospectively or retrospectively. Prospective assignment, already provided in the Pioneer and Next Generation demonstrations and in Track 3, allows ACOs to manage a less unstable patient population. The Committee states further ACOs that choose prospective assignment “should receive an upfront collective payment.” Providers choose Track 1 specifically to avoid an “upfront collective” or capitated payment. At first blush this proposal appears to make little sense. However, the Committee may have stumbled onto something. One of the primary criticisms of the ACO program is that it is a pay for performance model designed simply to lower spending. Since ACO providers are still paid FFS they have no incentive or ability to innovate to reduce costs by offering non-FFS reimbursed services. If Track 1 ACOs were allowed to choose prospective assignment in their second or third year or allowed to manage a subset of prospectively assigned beneficiaries under an “upfront collective payment” they would then be able to offer more widely skilled nursing, home health and other services CMS has been unwilling to allow, the same array of MA supplemental services and other or additional long term services and supports. Allowing Track 1s the opportunity to take a more incremental step toward downside risk might remedy the current stand off between CMS and the provider community that, as noted above, has led to limited industry interest in signing ACO risk sharing contracts.
The Committee proposes CMS develop a laundry list of quality measures to improve chronic disease care that includes measures for patient engagement, care planning and shared decision making. Problems with the current state of quality measurement are well recognized. For example, if better quality lowers costs, the ACO quality measure set is a failure. In the 2014 performance year, out of the 60 ACOs that earned quality scores at or above 90 percent only 22 earned shared savings. Instead of identifying what measures or more measures there would be benefit if the Committee encouraged how measures are developed. As Michael Porter has argued, value or quality in health care should be measured by calculating the outcome attained for a specific condition (the numerator) over the total costs of a full cycle of care (the denominator). In addition, the Committee may want to consider how measures are reported. They should be reported at the group not individual level to encourage team work and care coordination. Providers should also be given the opportunity to develop self-reported quality measurement systems as has occurred in California. Providers would then have the option to report their self-reported measures, that are independently audited, or report via national reporting mechanisms such as the Group Practice Reporting Option (GPRO). This would in part encourage measurement ownership and enable providers to receive far more timely performance feedback. Provider performance should also be scored and rewarded based on the higher of two scores: quality performance attainment; or, quality performance improvement. This approach would in part level the playing field between providers in wealthier versus those in poorer communities.
Additional Proposed Options
The Committee is proposing several additional policy options Hill staffers would collectively term cats and dogs. The Committee is proposing: ways to improve the Hierarchical Condition Categories (HCC) risk adjustment model; proposing to expand the Independence at Home demonstration; extend Special Needs Plan program authorization; create two new chronic care management codes; improve Centers for Medicare and Medicaid Innovation (CMMI) transparency; expand beneficiary education; and, require two prescription drug use, not cost, studies.
Again, the Committee and staff deserve praise for their effort. Going forward, if the Committee holds to its cost neutral commitment members will need to convince the CBO telehealth services are substitutive, not duplicative. The Committee faces the same possible problem or limitation in creating new chronic care management codes and expanding or extending Medicare programming. It too is an election year and the bill currently has no comparative effort underway in the House. Hurdles or headwinds aside, one is left to wonder about other chronic care policy options not included in the memo. To name one it is beyond understanding how the Committee, along with CMS, continue to ignore the oral health of Medicare beneficiaries. Medicare has never covered routine oral/dental care despite the widespread prevalence of oral health disease and edentulism and, per the CDC, “profound” oral health disparities particularly when research shows treating periodontal disease among individuals with type 2 diabetes for example is associated with lower total health care costs.
David Introcaso is a healthcare policy consultant based in Washington DC. David’s acute care experience is via DC General Hospital and in post acute via in part his work with National Hospice and Palliative Care Organization, he consulted with a wide array of clients including the American Heart Association and the American Public Health Association and has taught as an adjunct at the University of Chicago and George Washington University. Over the past four years David has interviewed over 90 health care experts in producing independently a health care policy podcast