Senate Finance Committee Floats Chronic Care Discussion Draft

October 27, 2016

The Senate Finance Committee released wide-ranging, bipartisan draft chronic care legislation Thursday (Oct. 27) that among other reforms would extend by two years the Independence at Home demonstration, let kidney-failure patients enroll in Medicare Advantage, ease telehealth restrictions, and change how beneficiaries could be assigned to accountable care organizations.

Jim Scott, a former CMS senior adviser who now is president and CEO of Applied Policy and who attended a briefingheld by a bipartisan Finance chronic care work group Thursday, said in an analysis of the draft that a final legislative package is expected in November. Earlier this summer, though, Senate Finance ranking Democrat Ron Wyden (OR) said he doubted Congress would pass a chronic care bill this year.

A summary of the discussion draft says offsets will be included, but does not say what those offsets might be.

Wyden began considering chronic care policies last Congress when he took over the committee from former Sen. Max Baucus (D-MT) and introduced what his website refers to as “The Wyden-Isakson-Paulsen-Welch Better Care, Lower Cost Act.” When Sen. Orrin Hatch (R-UT) became chair after Republicans won the Senate, Hatch continued working with Wyden on chronic care reforms and appointed committee members Johnny Isakson (R-GA) and Mark Warner (D-VA) to spearhead a chronic care initiative.

The committee released a long list of chronic care policy options at the end of 2015, and sent a letter to HHS Secretary Sylvia Burwell on Thursday saying Hatch, Wyden, Isakson and Warner were pleased that CMS had included four policies from that list in the proposed 2017 physician fee schedule — the expansion of the diabetes prevention program model, a new code to reimburse physicians for prolonged chronic care management services, integration of behavioral health care and a new code to pay for cognitive and functional assessment and care planning for Medicare beneficiaries with cognitive impairment. The lawmakers urge CMS to finalize those policies. The final rule is currently under review by the White House Office of Management and Budget.

“It is promising that the CCWG’s [Chronic Care Working Group’s] efforts are already driving care improvements for Medicare beneficiaries with chronic illness. There is still more work to be done, however, and the CCWG remains committed to developing bipartisan legislation that ensures Medicare beneficiaries with chronic conditions receive the coordinated, high quality care that they need and deserve,” the letter says.

The following is a rundown of the discussion draft floated Thursday.

Independence at Home extension. The discussion draft would extend the Independence at Home demonstration for two more years through September 2019, and increase the cap on the number of participating beneficiaries from 10,000 to 12,000. It would also allow practices up to three years to earn shared savings before they are removed from the program, rather than two.

CMS and lawmakers touted the Independence at Home Demonstration for saving millions two years in a row, although more than half of the second year’s savings will go toward incentive payments. CMS also said the participating practices improved quality from the first performance year in at least two of the six quality measures for the demo.

Sens. Ed Markey (D-MA), John Cornyn (R-TX), Michael Bennett (D-CO) and Rob Portman (R-OH) introduced a bill earlier this year to make the demonstration permanent and remove a limit on the number of participating beneficiaries. But Scott said committee staff at the chronic care meeting Thursday indicated the draft legislation only extends the program for two years because of the Congressional Budget Office’s estimates of how much it would cost to make the program permanent. Scott said CBO’s skepticism about cost savings resulting from innovations seemed to play a big role in the working group’s moderation of its initial proposals.

Special Needs Plans. The draft legislation would make special needs plans (SNPs) permanent. The duals SNPs, institutional SNPs, and chronic condition SNPs were last reauthorized through 2018 as part of the Medicare Access and CHIP Reauthorization Act.

The draft legislation would also require D-SNPs to have a unified grievances and appeals process in place by 2020. The Medicare-Medicaid Coordination Office would be directed to serve as a point of contact to help with integration efforts and to help establish one grievance and appeals process for D-SNPs. By 2021, D-SNPs would need to integrate Medicare and Medicaid behavioral health services.

C-SNPs would need to meet additional requirements under the draft bill to improve care management for beneficiaries with severe or disabling chronic conditions by the start of 2019. By the end of the year, HHS would need to update the list of chronic conditions eligible for participating in a C-SNP based on the health needs of a condition, providers and models of care required, and how common a chronic condition is in the Medicare population. A summary of the draft legislation says that CMS may consider implementing a quality star rating system for SNPs.

Kidney Care Partners commended the lawmakers for a number of their recommendations, and said the group supported extending the C-SNPs authorization without any interruptions.

Medicare Advantage changes. Kidney Care Partners also said they supported the draft’s provision to allow End-Stage Renal Disease beneficiaries to choose a Medicare Advantage plan.

The House Ways & Means Committee in July passed a bill to let kidney failure patients enroll in MA plans, and Kidney Care Partners have said the Senate Finance Committee’s chronic care initiative offered a good chance to undo the ban on kidney-failure patients entering MA plans.

The discussion draft would also expand the innovation center’s Value-Based Insurance Design model to let MA plans in any state participate during testing to see if the model leads to savings. MA plans would be allowed to offer more supplemental benefits to chronically ill beneficiaries, as well.

MA risk adjustment would also be changed under the discussion draft. CMS would need to take into account the number of diseases a beneficiary has, use at least two years of diagnosis data, and consider dual eligible status to improve the accuracy of risk adjustment. CMS would also need to evaluate including additional codes related to mental health, substance use, chronic kidney disease and other factors in the ESRD-risk adjustment model.

These changes would be phased in over three years, a summary of the discussion draft says, and Congress’ Medicare advisers would need to evaluate how they affect the accuracy of MA risk scores.

Telehealth. The discussion draft also eases restrictions on telehealth. Under the draft legislation, MA plans could include additional telehealth benefits in their annual bid amounts beyond what’s currently allowed under Part B, though a summary of the draft says this would not be a substitute for meeting network adequacy requirements.

ACOs could also use more telehealth, as the draft would apply the Next Generation ACO telehealth waiver to the Medicare Shared Savings Program ACOs in Track 2 and 3 as well as the Pioneer ACOs.

The draft would also eliminate the geographic restrictions on telehealth to pay physicians conducting telehealth consultations for beneficiaries with a stroke. It would also make it easier for beneficiaries who receive home dialysis to use telehealth for required monthly assessments starting in 2018.

ACOs. The draft bill would give Medicare ACOs the choice to have beneficiaries assigned prospectively at the beginning of a performance year, and allow beneficiaries to voluntarily choose an ACO that their main primary care provider participates in.

An ACO Beneficiary Incentive Program would also be created by the draft bill. The program would allow ACOs to make incentive payments to assigned beneficiaries that have qualifying primary care services. ACOs could offer a flat payment of up to $20 per qualifying service directly to a beneficiary. The summary of the bill notes that President Obama’s fiscal 2017 budget included a similar policy.

Government Accountability Office studies. The discussion draft directs GAO to conduct studies on improving medication synchronization, longitudinal comprehensive care planning services for a beneficiary diagnosed with a serious or life threatening condition, and the impact of obesity drugs on patient health and spending.

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