advocates this week praised new bipartisan legislation
in the House and Senate that aims to improve care coordination
for chronically ill Medicare patients under a structure different from accountable care organizations
The Better Care, Lower Cost Act of 2014
would remove federal rules and practices that keep providers from specializing in chronic care, urge nurses and physicians to lead care teams, and target areas of the country where chronic disease is widespread. It was introduced by Sens. Ron Wyden (D-Wash.) and Johnny Isakson (R-Ga.) and Reps. Erik Paulsen (R-Minn.) and Peter Welch (D-Vt.).
The bill would set up a Better Care Program, or a BCP, which differs from a Medicare
accountable care organization in several ways. For instance, the ACO's attribution rule prevents providers in ACOs from actively targeting and enrolling the sickest patients. There would be no such rules for BCPs. Also, a BCP would be required to have a tailored plan unique to the needs and conditions of each individual. While ACOs are eligible for shared savings if they reduce costs while meeting quality benchmarks, they continue to operate in a fee-for-service system. BCPs would be paid a fixed amount for each enrolled beneficiary, who would be required to seek care within the BCP network. Medicare ACO patients can choose to receive care out of network with no financial disincentive. This legislation would also allow nurses and physicians to lead care teams and the bill would prioritize areas of the country where chronic disease is widespread.
Some leaders of health systems involved in the Medicare ACO program have said it's necessary to lock beneficiaries into the network to most effectively improve care and reduce costs. But it's unclear how Medicare patient advocacy groups will respond to the legislation, given the limits on patients' free choice of provider under the model.
“Our experience with lock-in provisions in the past is that they are too often a disservice to patients, who find themselves with unexpected healthcare needs that can't be met within their plan,” Judith Stein, executive director of the Center for Medicare Advocacy, said in an e-mail.
A spokeswoman for Wyden's office said the legislation would actually add a new option for Medicare beneficiaries. The idea here, he said, is that Medicare beneficiaries would be attracted to the “continuity of a high-quality, intensive, team-based care model that has produced better health outcomes for patients.”
The Partnership for Quality Home Healthcare applauded the bill, citing statistics from Avalere Health that found 75% of Medicare home health beneficiaries live with four or more chronic conditions, compared with 48.5% of non-home health Medicare beneficiaries. That means home health providers are well-trained to serve this patient population, according to the Partnership. It said skilled home healthcare is the lowest-cost venue for treating and managing chronic conditions.
“As the most cost-effective senior care setting, home health is essential to providing high-quality, cost-effective care,” Eric Berger, CEO at the Partnership for Quality Home Healthcare, said in a written statement. “The Partnership looks forward to working with Senators Wyden and Isakson and Representatives Paulsen and Welch to ensure timely passage of this important measure and strengthen chronic-care delivery for our nation's sickest seniors.”
Dr. Michael Fleming, chief medical officer at Amedisys, a large home health and hospice company, said his company and other post-acute providers provided congressional staff with comments on chronic-care reform last summer. A strong supporter of the legislation, Fleming said the entire post-acute care continuum “is going to change tremendously,” and home health will play a huge part in that change.
“When you look at patients who have chronic diseases, they have more needs,” said Fleming, a past president of the American Academy of Family Physicians. “It's much better to take care of those patients in non-hospital settings,” he said. A team of professionals that includes social workers, nurses, therapists and physicians—along with telehealth services—will be essential in this kind of program, he added.
The bill will have an uphill climb this year, as lawmakers will focus on the debt ceiling increase, Medicare physician payment reform, and their own re-election campaigns. But Fleming said he isn't worried or discouraged about the timeline for this legislation.
“I'm very heartened by the fact that we're just talking about this,” Fleming said. “For too long, we've not recognized the importance of going after the chronically ill. The fact that we're having this conversation and talking about this is very important. So whether we pass (it) this year or next year or the year after that—I'm okay with that.”
Both the House and Senate this week passed the 2014 omnibus spending bill
that boosts discretionary spending for certain healthcare programs but does not provide new funding for implementing the healthcare reform law. The legislation now moves to the president's desk for his signature. On Friday, Dr. Darrell Kirch, president and CEO of the Association of American Medical Colleges, called the spending bill agreement a “vital first step” to restoring some stability to the congressional budget process and cheered the measure's $1 billion increase in funding for the National Institutes of Health. “Additionally, by preserving support for the Health Resources and Services Administration's health professions training programs, including Title VII and Children's Hospitals Graduate Medical Education program, lawmakers are helping support the next generation of health professionals that will be needed to respond to the increasing demand of the country's changing healthcare needs,” Kirch said in a statement. The legislation freezes management and operations at the CMS at a level of $3.7 billion, which is equivalent to the amount put in place by sequestration and $195 million below last year's funding level. It also directs the transfer of $1 billion from the reform law's Prevention and Public Health Fund to specific funds and programs within HHS.
2014 is an important year for the Patient Protection and Affordable Care Act, but will it also be the year that GOP lawmakers offer an alternative for reforming the nation's healthcare system? Since they took back control of the House in 2011, House GOP leaders have vowed to “repeal and replace” President Barack Obama's
signature piece of domestic policy legislation. Repeal votes came time and again in the past three years, but there's been no sign of replacement legislation. In his weekly news conference Thursday, House Speaker John Boehner (R-Ohio)
hinted that might change this year. The Ohio Republican said healthcare will be one of the major topics of discussion at the GOP retreat later this month. “It's one of the big issues for conversation in terms of our agenda for this year,” Boehner said. “And I think you'll see Republicans come forward with a plan to replace Obamacare—a plan that will actually reduce costs for the American people and make health insurance more accessible.” But many political observers say there is a wide gulf among Republicans about how to go about healthcare reform which has blocked them from offering an alternative in the past, and that has not necessarily changed.Follow Jessica Zigmond on Twitter: @MHjzigmond