Industry asks Congress for more leeway on Medicare Advantage, telemedicine coverage

Expanding telemedicine coverage and changing rules that govern Medicare Advantage, ACOs and value-based insurance designs would all help improve health and reduce spending on Medicare patients with multiple chronic conditions, said witnesses at a Senate Finance Committee hearing on Tuesday.

The Senate's bipartisan Chronic Care Working Group has already gotten six of its policy proposals realized through CMS rulemaking and the 21st Century Cures Act. Its remaining priorities will make a big difference, according to a doctor, health plan administrator and hospital system administrator who testified.

Currently, Medicare reimburses telemedicine only in rural areas and immediate access to care can sometimes make a huge difference.

Dr. Lee Schwamm, director of the Partners Telestroke Network at Massachusetts General Hospital in Boston, told senators that patients given a clot-blusting drug, if administered within 90 minutes of symptoms starting, are almost three times more likely than other ischemic stroke victims to recover with little to no disability.

But if a stroke neurologist is not in the ER or on call, doctors may hesitate to administer the drug, because it will make a less common kind of stroke worse.

There's a lot of room for improvement, Schwamm said, as only 2.4% of Medicare patients who had ischemic strokes received the drug in time. And, he said, after implementing telestroke networks, hospitals at least doubled the number of patients getting the drug in the critical time window.

"Telestroke is supported by a wealth of evidence and is a common-sense, cost-effective step that the committee can take to reduce the burden of stroke as a chronic disease," Schwamm said.

The committee hopes to pass its remaining priorities in the CHRONIC Care Act this year.

The bill would allow Medicare Advantage plans to spend taxpayer money on social supports, such as delivering meals tailored to patients with diabetes or congestive heart failure; rides to doctors' appointments; and home modifications. Under current law, any add-ons in Medicare Advantage have to be available to all plan members.

Katherine Hayes, director of health policy at the Bipartisan Policy Center, said a pilot study found that bringing such supports to people with multiple chronic conditions reduced medical costs by as much as 27%.

Medicare Advantage already has the authority to design plans for complex patients like these who also qualify for Medicaid funding under special needs plans, but the bill would make pecial needs plans a permanent part of the Advantage program. John Lovelace, president of the UPMC system's Medicare Advantage, CHIP and Medicaid plans, said UPMC has been offering special incentives for people with diabetes, congestive heart failure and depression to encourage them to talk to health coaches and set goals to improve their health. This sort of approach should be available more widely, he said, not just in the seven states experimenting with value-based insurance design in Medicare Advantage. CHRONIC Care Act would expand value-based insurance design and also allow accountable care organizations to pay up to $20 per qualifying service, directly to the beneficiary to encourage them to stay engaged in treatment.

Lovelace, in response to a question from Sen. Debbie Stabenow (D-Mich.), acknowledged that they don't yet known whether their value-based, insurance design, four-phase $100 incentives are working. But he said UPMC runs commerical programs that use incentives and have moved the needle.

He said among 65,000 UPMC employees, 85% have agreed to wellness and health coaching in order to lower their insurance deductible by $1,000. He said the plan learned that a $500 deductible was not enough to spur participation. Sen. Tom Carper (D-Del.) asked Montefiore Health System's Stephen Rosenthal what one piece of advice he would give the Senate to reverse the obesity epidemic, which is a factor in many of the chronic conditions that become expensive during Medicare years.

"It begins in the schools," said Rosenthal, senior vice president for population health management. He said by adolescence, many kids are already obese and it's much harder to lose weight once you've gained it than to prevent weight gain from the start through teaching good eating habits and how to incorporate exercise into their lives.

The CHRONIC Care bill does not address that kind of prevention, but this month, the U.S. Department of Agriculture rolled back whole grain and milk rules that were part of nutrition improvements to school lunches championed by former first lady Michelle Obama.

While it was not one of the aspects receiving attention during the hearing, CHRONIC Care also extends Independence at Home demonstration sites to 15,000, revises its expiration to Sept. 30, 2019, and allows practices three years rather than two to achieve shared savings targets. Under current law, practices have to leave the demonstration if they don't achieve savings in two consecutive years.