CHRONIC Care Act – Improving Care Management And Care Coordination At Home


Despite the overwhelming amount of news coverage and focus on the gridlock that has characterized the healthcare debate for several months now, bipartisan efforts are underway—with little fanfare or coverage—that can assure us progress is being made to improve the coverage and experience of individuals with complex care needs. Some of these efforts, such as the focus on improving Value-Based care and alternative payment models, have been covered in previous blogs. Today’s focus is a bill recently passed in the Senate, and received by the House for consideration on September 27. That bill, Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act the CHRONIC Care Act of 2017 (S.870), was sponsored by Utah’s Orrin Hatch and co-sponsored by 11 Democrats and 9 Republicans.

Aiding in the bill’s likely passage in the House is the CBO report that has given it a favorable score, saying it would neither add to nor decrease Medicare spending over the next decade. The CHRONIC Care Act specifically targets Medicare payment reform, an idea that has already received bipartisan support through the passage of other bills. Its goal is to push Medicare costs down by improving chronic disease management services and care coordination at home.

Budget Breakdown

The CBO estimates that the bill would likely cost about $313 million–$50 million to increase ACOs flexibility to use technology, $50 million to expand the ACO population to include beneficiaries with chronic conditions, $90 million by adding telehealth to Medicare Advantage plans, and $123 million to provide access to MA special needs plans for vulnerable populations. These costs would be offset by a projected $80 million in savings through Medicare Advantage plans and $375 million saved by eliminating the Medicare and Medicaid Improvement Funds.

The CHRONIC Care Act of 2017 specifically amends title XVIII (Medicare) of the Social Security Act to:

  • Extend the Independence at Home (IAH) demonstration program
  • Modify provisions regarding access to home dialysis therapy under Medicare and special needs plans under Medicare Advantage (MA)
  • Expand testing of the MA Value-Based Insurance Design test model
  • Allow an MA plan to provide additional telehealth benefits to enrollees and, to chronically ill enrollees, certain supplemental health care benefits
  • Modify other provisions regarding the use of telehealth services
  • Allow prospective, voluntary assignment of Medicare fee-for-service beneficiaries to accountable care organizations (ACOs)
  • Allow ACOs to operate beneficiary incentive programs

Independence at Home Program

The Independence at Home (IAH) program, extended by this bill, has proven successful since it began in 2012. Though currently set to expire this year, it would be extended through 2019 if approved by the House. Its cap on the total number of participating beneficiaries would also be increased from 10,000 to 15,000. Providers participating in this program have nurses and physicians who provide in-home visits to those with chronic illnesses and must be available 24 hours per day for their patients. Under the IAH program, qualifying ACOs and practices continue to receive their standard fee-for-service payments, but are also eligible for incentive payments that depend on their meeting performance standards and quality measures designed to improve the care for the chronically ill.

Another significant benefit is expanding access to home dialysis therapy for the chronically ill. Beneficiaries of home dialysis therapy must meet monthly with their clinician to review lab work and check for complications. For those utilizing telehealth for these consultations, Medicare currently requires they occur at an authorized originating site, such as a hospital or physician’s office, or a site located in a rural Health Professional Shortage Area (HPSA) or area outside a Metropolitan Statistical Area (MSA). Beginning in 2019, this bill seeks to expand the number of originating sites, including freestanding dialysis facilities and even the patient’s home. Geographic restrictions would also be greatly reduced.

Integrating Primary and Behavioral Healthcare

Some of the policies promoted by the CHRONIC Care Act were already being administratively executed in 2016, such as promoting the integration of behavioral health care and primary care services and establishing a new code to pay for assessment and care planning for beneficiaries with Alzheimer’s disease and other cognitive impairments. Of particular interest is the focus on integrating primary care with behavioral health care, such as mental health and substance use disorders. Positive steps have been taken to more tightly integrate the general medical and behavioral health communities and promote primary care providers to better coordinate patient care with trained behavioral health practitioners.

In recent years, Chronic Care Management (CCM) and other similar programs have been exclusively for physical health. Efforts were made in 2016 allowing mental health practitioners to participate as well, and have resulted in the CHRONIC Care Act continuing to reward and encourage collaboration. Behavioral Health professionals applaud these efforts, but believe they are only the beginning. Charlie Hutchinson of InSync Healthcare wrote in Behavioral Healthcare Executive that continued efforts from behavioral health providers must include:

  • Embracing healthcare technology – The physician community has largely embraced healthcare tech, such as in expanding payment methods, due to program incentives that were not available to mental health providers. As a result, there is a disparity in the use of technology between physical and mental health providers. The latter must use technology capable of sharing patient records to assist in care coordination and collaboration
  • Advocating for change – The past year has provided great progress, such as the 21st Century Cures Act (signed into law December 13, 2016) and other state laws. These successes have provided a growing voice to mental health providers, but ensuring that voice continues to be heard will require ongoing and increasing advocacy

With passage in the House of the CHRONIC Care Act very likely, we can anticipate improved care for high-risk Medicare beneficiaries suffering from chronic illnesses. There is certainly cause for hope, as this and other legislative successes have shown us that partisan politics isn’t all that happens in Washington, and that both sides of the aisle can come together for the common benefit of improving healthcare for providers and patients alike.

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