The pace of change in the United States’ health care system is accelerating. Building on work by private and public payers, Centers for Medicare and Medicaid Services (CMS) officials are pursuing a transformation of how our health care system pays for care, spurred on by the passage of last year’s bipartisan sustainable growth rate (SGR) reform legislation and Health and Human Services (HHS) Secretary Sylvia Mathews Burwell’s own payment reform goals. The destination is a wholesale transition away from the incentives for volume over value inherent in fee-for-service medicine.
But even as recent press coverage and HHS announcements suggest that reform is picking up speed, providers and plans are facing significant speed bumps. It’s time that Congress give providers and plans the tools needed to deliver on the promise of better care at lower cost.
To be sure, HHS’ efforts are promising. On July 7, regulators offered up a draft Medicare physician payment rule which bolstered reimbursement for care coordination and planning and covered diabetes prevention programs. The Center for Medicare and Medicaid Innovation (CMMI) has announced sweeping tests of bundling and medical home models. Secretary Mathews Burwell has already deployed the Affordable Care Act’s expansion authority to implement elements of the Pioneer Accountable Care Organization (ACO) Demonstration and the Diabetes Prevention Program. And this November 1, after sorting through 3,874 public comments, CMS will issue its final rule implementing payment incentives for physicians and clinicians to participate in alternative payment models.
Yet the truth is that the underlying Medicare law was built for a purely fee-for-service system. And as alternative payment models evolve and grow, they are encountering significant statutory barriers to their success — barriers that only Congress can bring down.
Barriers to Transformation
Consider the circumstances facing high-cost, high-need traditional Medicare beneficiaries. For these patients—typically living with multiple chronic conditions—failures of care coordination are particularly serious, with the potential to trigger hospital readmissions, nursing home stays, further functional decline, or even disability and death. For most, no one single clinician or entity has responsibility for all their care over time.
Since 2011, the Independence at Home (IAH) Practice Demonstration has given 90,000 such beneficiaries access to a team of doctors, nurses, pharmacists, and social workers who provide high-quality primary care in the beneficiaries’ own home. This demonstration has yielded a remarkable $3,070 in annual savings per beneficiary while improving quality. Unfortunately, the amendment to the ACA which established the Demonstration explicitly excludes this particular demonstration from the Secretary’s authority to expand cost-saving or quality enhancing payment models. As a result, 2 million of the costliest, neediest Medicare beneficiaries’ lack access to this very successful care model built for their unique needs.
For those 17 million beneficiaries in Medicare Advantage and the approximately 10 million beneficiaries in a Medicare ACO, the situation can be better. Payment structures and quality metrics for plans and ACOs are intended to incentivize better quality at a lower cost. But here as well, current law presents obstacles, denying plans and ACOs the tools they need.
Take the example of high-tech telehealth and remote monitoring technology. Health plans and providers outside of Medicare have harnessed telehealth strategies to improve care for chronic disease, speeding up the assessment of stroke patients in the moments following their stroke and remotely monitoring chronic heart failure (CHF) patients’ weight to detect flare-ups. But with just a few exceptions, Medicare requires that care be delivered in-person. Consequently, Medicare spent only $14 million on telemedicine in 2014 out of a total $608.7 billion budget.
Similar barriers discourage innovative high-touch approaches. Specialized health plans like SCAN Health Plan in California and Commonwealth Care Alliance in Massachusetts have learned that targeting long-term services and supports, like a visit from an in-home aide or a wheelchair ramp, can keep dually eligible beneficiaries in their homes and out of nursing homes and hospitals. But because these services are not considered ‘medical,’ Medicare bars use of these interventions with Medicare-only enrollees — even if they could keep more beneficiaries out of institutions and off Medicaid in the first place.
In Original Medicare, providers in Accountable Care Organizations and other alternative payment models (APMs) face similar challenges. Outside of a few narrow exceptions under the Medicare Shared Savings Program, federal Civil Monetary Penalty restrictions bar providers from providing services or other inducements to encourage a beneficiary to patronize a particular provider. As a result, some question exists whether providers and APM entities are permitted to provide high-touch interventions not covered by the normal Medicare benefit, to their attributed beneficiaries.
Finally, current law and policy also restricts consumer engagement by Medicare providers and plans. For example, value-based insurance designs (VBID) that lower cost sharing for high-value services for specific patient populations (like primary care visits or statins for hypertension patients) improve outcomes and lower costs. However, the policies governing Medicare Advantage (MA) plans, as set forth in the Medicare Managed Care Manual, explicitly require that, “premiums and cost sharing must be uniform” in each service area or segment of a service area. This overly rigorous interpretation of Medicare’s uniformity and anti-discrimination rules effectively bars most MA plans from targeting cost sharing reductions to specific patients with chronic conditions. CMMI is currently testing a Value-Based Insurance Design Model that lifts some of those restrictions, but this promising test is limited to just seven states.
These various barriers would be maddening enough if they denied Medicare beneficiaries their shot at better care at a lower cost. But they impact those of us who get our coverage elsewhere, too.
Medicare’s policies have an outsized influence on our health care system. If the biggest payer, Medicare, does not reimburse for a particular service or deploy a benefit innovation, providers and plans have less incentive to develop, test, and expand those features. Then the rest of us are stuck paying for a less efficient health care system through higher premiums, higher taxes, and higher deductibles and copays.
Accelerating Transformation
How can we bring down these barriers?
A first step would be ensuring our public programs do, in fact, expand payment and delivery models that work. Most immediately, Congress should convert Independence at Home to a permanent, national voluntary option available to high-cost, high-need Medicare FFS beneficiaries. To do just that, Senators Markey, Cornyn, Bennet, and Portman recently introduced the Independence at Home Act. But even as this new legislation advances, lawmakers must also resist calls to restrict authorities to test and scale other alternative payment models granted to the Centers for Medicare and Medicaid Innovation and the Secretary of Health and Human Services.
Secondly, lawmakers need to modernize the Medicare statute to promote innovation in care delivery. Such an effort should begin by passing the bipartisan, bicameral CONNECT for Health Act, which lifts outdated restrictions on use of the high-tech telehealth technology in Medicare. Simultaneously, Congress should also enact legislation empowering plans and providers to deliver high-touch long-term services and supports.
Finally, Congress can help providers and plans engage consumers by lowering cost barriers to high-value care. This requires enabling Medicare Advantage plans in every state to reduce cost sharing for subsets of beneficiaries with chronic conditions as well as permitting ACOs to waive cost sharing for high-value and primary care services.
Taken one at a time, none of these steps sound revolutionary. But together, they will accelerate the transition toward more affordable, higher quality health care in Medicare and across our health care system. It is time that our elected representatives on Capitol Hill took them.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2aG4IiK
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