A bipartisan group of Senators is proposing ways to improve health outcomes for Medicare beneficiaries with chronic conditions, which account for the majority of Medicare spending.
Sens. Orrin Hatch, R-Utah, Rob Wyden, D-Oregon, Johnny Isakson, R-Georgia, and Mark Warner, D-Virginia, released a draft of a bill that will be called the Chronic Care Act. It’s the result of a year and a half of work on the Senate Finance Committee’s Chronic Care Working Group, according to Hatch.
“Left unresolved, chronic care’s impact on beneficiary health outcomes and Medicare program spending could quickly worsen,” Hatch said in a statement. “Developing and implementing policies that improve disease management, streamline care coordination, improve quality, and reduce Medicare costs is a challenge. But with strong bipartisan leadership, we can continue to work together to advance innovative policies that improve care transitions, produce stronger patient outcomes, and increase efficiency without adding to the deficit. I look forward to continuing that discussion.”
Here are five Medicare reforms outlined in the draft version of the bill:
1. Choosing an ACO
The proposal will seek to “provide flexibility for beneficiaries to be a part of accountable care organizations (ACOs),” allowing beneficiaries to choose to participate in an ACO directly rather than only being notified if their provider is part of one.
“Prospective assignment allows ACOs to identify beneficiaries for whom they will be held accountable and proactively take steps to connect these beneficiaries to appropriate care, but also holds ACOs accountable for the spending for these beneficiaries even if the ACO providers do not provide the care,” a summary of the bill explained. “Retrospective assignment ensures that ACOS are held accountable for the spending only of those beneficiaries who receive most of their primary care services from ACO providers, but they may not know who those beneficiaries are until the end of the year.”
ACOs within the Medicare Shared Savings Program would have the choice to have beneficiaries assigned prospectively at the start of a performance year. HHS would have to create a process to notify beneficiaries of the ability to voluntarily align to the ACO which their primary care provider is participating or to change providers.
As encouraged by letters from the College of Healthcare Information Management Executives (CHIME), increased use of telehealth is included in the proposal, expanding its coverage in Medicare beyond services which currently receive payment under Part B. Medicare Advantage plans would “offer additional, clinically appropriate, telehealth benefits in an annual bid amount,” but it would leave what services to cover to HHS.
“The secretary would be required to solicit comments on what types of telehealth services offered as supplemental benefits should be considered to be additional telehealth benefits,” the bill said. “The use of these technologies would not be a substitute for meeting network adequacy requirements, and the beneficiary would have the ability to decide whether or not to receive the service via telehealth.”
Stroke patients would also receive expanded access to telehealth, with “timely consultations” on stroke symptoms for beneficiaries at rural hospitals being covered beginning in 2018.
3. Payment changes for Medicare Advantage
Under the draft bill, “accurate payment” for Medicare Advantage (MA) plans covering beneficiaries’ chronic conditions would be ensured. The current payment model would be adjusted over a three-year phase-in period to include the total number of diseases, two years of diagnosis data, Medicare-Medicaid dual eligibility status, as well as consider including diagnosis codes for mental health, substance abuse and chronic kidney disease.
The bill would also allow MA plans in all states to participate in CMS’ Value-Based Insurance Design (VBID) Model during its testing phase.
4. Expanding MA benefits, including for end-stage renal disease
MA plans would be able to offer a wider array of supplemental benefits for beneficiaries for chronic conditions. That could include additional inpatient hospital days in a psychiatric or acute care facility or counseling services.
“These supplemental benefits would be required to have a reasonable expectation of improving or maintaining the health or overall function of the chronically-ill enrollee and would not be limited to primarily health related services,” the bill’s summary said. “The section would allow an MA plan the flexibility to provide targeted supplemental benefits to specific chronically ill enrollees.”
The bill would also allow Medicare’s under-65 End-Stage Renal Disease (ESRD) beneficiaries to enroll in any MA plan beginning in 2021. For help to “eliminate uncertainty” for plans covering these patients, the standard acquisition charges for kidneys would be removed from the MA benchmark and bid by CMS, with those charges paid like a fee-for-service beneficiary.
5. Expanding home care services
To increase the use of home care by Medicare beneficiaries, the bill would extend the payment and service delivery model known as Independence at Home (IAH). The demonstration is scheduled to end in 2017, but the legislation would push back its expiration to 2019 and expand the program to a total of 12,000 beneficiaries.
The legislation would also expand telehealth into a patient’s home for dialysis therapy. Rather than requiring a beneficiary receiving dialysis to make a monthly trip to their clinician, they would be able to consult with a nephrologist via telehealth without any geographic restriction. An in-person assessment would still be required every three months.