January 26, 2016

United States Senate Committee on Finance
Bipartisan Chronic Care Working Group
219 Dirksen Senate Office Building
Washington, DC 20510-6200
chronic_care@finance.senate.gov

Thank you for the opportunity to comment on the Bipartisan Chronic Care Working Group Policy Options Document. These options include many opportunities to improve the quality and value of chronic care, and several align with efforts underway here at the National Committee for Quality Assurance. (NCQA).

Receiving High-Quality Care in the Home: We support expanding this demonstration that improves care for beneficiaries with multiple chronic condition via home-based primary care, quality metrics and shared savings. It importantly provides comprehensive patient-centered care to a high-cost, vulnerable population that greatly needs higher quality care. It also aligns with ongoing NCQA efforts to improve care for such vulnerable populations by focusing on individual patient’s own goals and priorities. We agree that hierarchical condition category risk scores provide a better way than non-elective hospitalizations to identify beneficiaries for inclusion in the program.

Advancing Team Based Care: We support requiring Medicare Advantage plans to provide full hospice benefits. We are developing measures that could be added to the MA five-star quality measurement system to address hospice coverage. They assess whether patients receive detailed needs assessments and comprehensive care planning built from individually-generated, often non-clinical goals, such as a desire to play with grandchildren, socialize or garden. Measuring attainment of individually-generated goals would be particularly important in a hospice population.

We support letting end state renal disease patients enroll in Medicare Advantage plans. These often complex patients can greatly benefit from the greater care coordination tools that MA plans have, and they may be best served by Special Needs Plans (SNPs) that are accountable for man aging their considerable and well-understood clinical needs. Several quality measures address priorities for these patients, such as Diabetes Eye Exam, Advance Care Plan, Medication Reconciliation Post Discharge and Influenza Immunization. Medicare could address ESRD patient needs in the star ratings system with these and similar measures used in the Comprehensive ESRD Care Model.

We support providing vulnerable populations continued access to Medicare Advantage SNPs. SNPs’ potential would be particularly enhanced by greater flexibility to tailor benefits to their unique populations, for example to waive cost sharing to improve use of high-value treatments, services and providers.

We support developing a new high-severity code to cover care management for individuals with multiple chronic conditions. This high-severity code would apply to enrollees with several, rather than, just more than one chronic condition under the current payment policy, and those with one or more serious chronic conditions. However, given the possibility that new therapies might alter management needs for specific conditions, you may want to ask the Secretary to develop and periodically update the list via regulations rather than lock specific conditions in legislation.

Better integrating behavioral care for individuals with other chronic diseases is a high yet largely unmet priority for improving quality for such individuals and our entire health care system. NCQA is working to improve behavioral care integration through measurement, accreditation and Patient-Centered Medical Homes and Patient-Centered Specialty Practice programs.

Expanding Innovation & Technology: As with SNPs, we agree that all Medicare Advantage plans should have greater flexibility to incorporate value-based insurance designs that reduce or eliminate cost-sharing barriers to high-value treatments, services and providers. For example, enrollees can benefit when plans reduce or eliminate cost sharing for care provided in Patient-Centered Medical Homes. MA plan enrollees also could benefit from greater flexibility to provide supplemental benefits, such as telehealth, social services and supports and condition-specific wellness interventions that reduce need for costly medical interventions.

High-quality plans may be better able to make use of greater flexibility in these areas in the short term. However, greater flexibility should over time be available to all plans, as it may be particularly useful in helping moderate-quality plans close the quality gap with better performing plans. Ambulatory care sensitive conditions, where good management by clinicians reduces need for costly inpatient care and complications, are prime candidates for such flexibility. Plans also should be allowed to propose novel uses of such flexibility for consideration by Medicare officials in order to promote further innovation.

Criteria for supplemental benefits should include whether they are demonstrated to improve quality of life, medical outcomes, or costs, and valued by patients. Medicare Advantage’s capitated payments ameliorate fraud, waste and abuse concerns that exist for supplemental benefits like telehealth in fee-for-service. Plans should thus have broad discretion on which supplemental benefits to adopt and how to use them.

The shared savings model also tempers such concerns about telehealth in Accountable Care Organizations (ACOs), which should have similar flexibility on which supplemental benefits to adopt and how to use them. We therefore support lifting the originating site requirements for telehealth payment in ACOs. The shared savings model also warrants clarifying that ACOs may furnish social or transportation services that can reduce need for costlier medical interventions.

Identifying Chronically Ill Populations & Ways to Improve Quality: We support changing CMS’ HCC Risk Adjustment Model to account for total number of conditions, cumulative impacts of large numbers of conditions, interactions between behavioral/mental and physical health, and use of more than one year of data. All of these improvements would make payment more accurate, fair, and sufficient to provide all needed care.

We also support, and are engaged in, developing additional chronic conditions quality measures. These include:

  • Standardized patient-reported outcome measures (PROM) that are particularly important for patients with chronic conditions or complex needs. PROMs also can help engage patients in their care and self-management and inform shared decision making for complex populations.
  • Measures to quantify progress in meeting patients’ own goals for care, such as improved ability to participate in family and social activities that is limited by their chronic conditions. This measurement approach provides a metric of the degree to which clinicians address the motility problems so the individual can achieve the goal.
  • Patient engagement, including confidence in self-care abilities, shared decision making, autonomy/choice, and achievement of a collaborative relationship with providers.
  • More and better measures that address hospice and end-of-life care. PROMs, patient goal and engagement measures can all support better measurement in this woefully underserved and critically important area.

Empowering Individuals & Caregivers in Care Delivery: We strongly support waiving cost sharing that might prevent beneficiaries from getting needed chronic care management services. You should also waive cost sharing for the proposed high-severity care management code. Eliminating financial barriers should improve access to these services and thus quality, patients’ experience of care and need for costlier services, which should help offset any cost from waiving cost sharing.

We also support payment for discussions on new serious diagnoses, such as Alzheimer’s. Discussion for any illnesses with under two years’ prognoses should qualify for reimbursement. However, you may want the Secretary to develop and periodically update the list of qualifying diagnoses in regulations based on such criteria rather than lock specific diagnoses in legislation.

We support letting two-sided risk ACOs waive cost sharing for services that treat or prevent chronic disease progression. The list of such services should be developed and periodically updated in regulations. We encourage you to also consider broader value-based insurance design in ACOs, for example letting them reduce cost sharing for high quality providers.

We support covering evidence-based lifestyle interventions to help pre-diabetics reduce risk of progression. Any entity – including non-profits such as the YMCA and health departments – with clear, objective evidence that their program reduces pre-diabetics’ progression rates should be able to bill for these services so beneficiaries have broad access to them.

Finally, we believe a study is warranted on whether coordinated prescription drug dispensing can improve medication adherence. Such a study should evaluate its impact on cost burdens on patients, for whether it eases or increases difficulty in making multiple copays at the same time. The study should also evaluate any impact on complications like use of dangerous drugs or drug-drug interactions.

Thank you again for inviting our comments. If you have any questions, please contact Paul Cotton, Director of Federal Affairs, at cotton@ncqa.org or (202) 955 5162.

Sincerely,

Margaret O’Kane,
President