A Bipartisan Approach to Better Care and Smarter Spending for Elderly Adults with Advanced Chronic Illness
Last December, the Chronic Care Working Group (CCWG) a bipartisan collaboration of Senate Finance Committee members chaired by Senators Isakson (R GA) and Warner (D VA) released its policy options document. The CCWG had a formidable charge to "analyze current law, discuss alternative policy options, and develop bipartisan legislative solutions" that increased care coordination across settings, streamlined Medicare payment while aligning incentives, facilitated high quality care, produced better outcomes, and reduced growth in Medicare spending. The requirement that proposals be budget neutral or cost saving narrowed the choices. After reviewing more than 530 comments, the CCWG met with 80 stakeholder groups, ultimately recommending 24 options, including two that focused on improving the infrastructure of chronic care with better quality measures and more accurate measures of cost for payment and computing shared savings. Of the proposals, 16 were for enhanced chronic care, with 11 focused on capitated payments (e.g. Medicare Advantage (MA) or shared savings (accountable care organizations (ACOs) Independence at Home (IAH) (Table 1) Despite government efforts to promote systems of care that feature cost containment strategies such as capitation (MA) or shared savings (ACOs) more than half of the 49 million Medicare beneficiaries continue to receive care from fee for service (Medicare A and B) providers, without spending constraints. Proposals to enhance care within traditional fee for service (FFS) Medicare were limited to new billing codes for high intensity chronic care management, counseling regarding prognosis of serious illnesses, and limiting constraints on telemedicine for specific patient groups. There is wide recognition that Medicare spending is concentrated in beneficiaries with advanced chronic illness. Nearly half of FFS spending is for 5% of beneficiaries, the 1.7 million with annual spending exceeding $54,000 per person, compared with $9,900 for the average Medicare beneficiary. Recognizing where spending is concentrated is necessary but is only the first step toward creating targeted policy to advance high quality care and reduce costs. Of the 34 demonstrations that CMS formally evaluated over the past 15 years, only two were substantially successful in reducing costs and increasing quality. The main lessons from these demonstrations are not surprising. There is value in targeting high cost beneficiaries and developing trusting human relationships where engaged patients and providers work toward common goals; there is significantly less cost savings and quality improvement in efforts where providers work by themselves, focus work on telephonic management, are disconnected from primary care, or focus merely on technologyassisted data acquisition and algorithm driven care plans. Two notably successful FFS programs Health Quality Partners and Massachusetts General Hospital (MGH) relied on administrative fees to pay for provider time and
Journal of the American Geriatrics Society