In 2014, the United States Senate Committee on Finance took a step toward improving care for the millions of Americans who are managing chronic illness. During a hearing entitled “Chronic Illness: Addressing Patients’ Unmet Needs,” Senators heard compelling testimony from individuals who are battling multiple chronic medical conditions, and who are seeking more effective tools to help them navigate the healthcare system. Senators have also heard from providers, employers, and health plans about the unique challenges each of them face in trying to offer quality healthcare at low costs.
The Senators in attendance at the first hearing began to understand the problems faced by many Americans, and they set a second hearing in May 2015, “A Pathway to Improving Care for Medicare Patients with Chronic Conditions.” During that second hearing, Senators once again heard testimony, this time from experts at the Centers for Medicare and Medicaid Services (CMS) and the Medicare Payment Advisory Commission (MedPAC). This hearing allowed Senators to better understand how current chronic care coordination programs are working today, the challenges that remain, and possible solutions to improve health outcomes for Medicare beneficiaries.
The May 2015 hearing prompted the creation of the Finance Committee chronic care working group, co-chaired by Senators Johnny Isakson and Mark Warner. The working group studied stakeholder input and comments and conducted 80 stakeholder meetings to discuss various ideas to improve the way care is delivered to Medicare beneficiaries with chronic diseases. After reviewing all submissions and taking into account all meetings, the working group outlined three main bipartisan goals that each policy under consideration should strive to meet. Each proposed policy should:
- Increase care coordination among individual providers across care settings who are treating individuals living with chronic diseases;
- Streamline Medicare’s current payment systems to incentivize the appropriate level of care for beneficiaries living with chronic diseases; and
- Facilitate the delivery of high quality care, improve care transitions, produce stronger patient outcomes, increase program efficiency, and contribute to an overall effort that will reduce the growth in Medicare spending.
The working group strives to operate in an open and honest fashion, and as such, has released an options document summarizing key policy ideas they are considering. This document remains a working document, and eventually the Committee and working group realize that they will have to involve the Congressional Budget Office (CBO) in scoring proposals to determine their impact on federal spending. The Chairman and Ranking Member both agree that any future legislation must either realize savings, or be budget neutral.
The policy ideas included in the options document are essentially grouped into six different categories: receiving high quality care in the home; advancing team based care; expanding innovation and technology; identifying the chronically ill population and ways to improve quality; empowering individuals and caregivers in care delivery; and other policies to improve care for the chronically ill.
While the Committee is not endorsing any of the options listed, it is unlikely that they will stray from the list when they eventually move to draft legislation next month. While some of the proposed options are obvious and beneficial, others are innovative and may help to innovate care delivery and advance CMS efforts to improve quality and value payment.
One obvious proposal made is to generally improve the integration of care for individuals with both a chronic disease and a behavioral health disorder. Behavioral health disorders are under-diagnosed and under-treated, and when combined with a chronic disease, make life excruciatingly tough. Members should explore lifting billing restrictions that prohibit qualified non-physicians from treating beneficiaries with behavioral conditions. Currently, clinical psychologists, clinical social workers, and medical family therapists, are qualified but excluded from billing under the chronic care management (CCM) code, evaluation and management codes, and Health Behavior Assessment and Intervention codes.
The Committee also touches upon the hot topic of telehealth by providing several ideas to expand it: permitting MA plans to include telehealth in their annual bid amount; waiving the originating site requirement for at risk ACOs; and expanding its use to encourage home hemodialysis and a more timely diagnosis of stroke.
The Committee proposed that CMS develop a list of quality measures to improve chronic disease care that includes measure for patient engagement, care planning, and shared decision making.
Currently, there is no comparative effort underway in the House of Representatives, and, considering it is an election year, it is uncertain how much work even the Senate will continue to put in on this effort. However, the Committee members and their staff deserve great praise for acknowledging such a serious issue, and working to create bipartisan solutions to solve it.
A list of public comments received on the options document can be found here, including comments from AARP, AdvaMed, American Medical Association, Biogen, PhRMA, and Sanofi.