The Senate is actually working on a good healthcare bill. No, not the AHCA or the doppelganger of the AHCA. The Chronic Act is winding its way through the committee process. This bill is full of little technical corrections to Medicare and tweaks for experiments. Let’s look at what’s happening in it.
Section 101 expands a demonstration project that has good initial results. The Independence at Home program is a pilot program that uses intensive primary care and care coordination to specifically target high risk and high cost Medicare beneficiaries for more intensive services. Its initial evaluation found significant savings and quality improvements. This section expands the time frame and the number of beneficiaries who can be enrolled in the study. The goal, I think, is to see how this project can scale up and move it towards a national model.
Section 102 allows for some telehealth visits to be used to supervise/coordinate dialysis care. This would be an option not a requirement. It should improve access and quality of life for people on dialysis who live far away from their nephrologists and clinics. It might save a little bit of money as the telehealth visit would not be allowed to charge a facility fee.
Section 201 modifies how care coordination is managed for individuals who are dual enrolled in Mediare Advantage and Medicaid through the SNP program. Care coordination meetings are mandated. Rules are to be developed for a uniformed complaints and grievances process. Eligibility is defined as either rare or costly. There is a section that warms the cockles of my heart on statistically validity of quality measures relating to population size.
Section 301 is a Medicare Advantage benefit design waiver pilot program. The concept of Value Based Insurance Design (VBID) is that patients should pay nothing for very high value care and a lot for low value care. In this frame work, insulin and test strips should be no cost sharing to Type 1 diabetics. Ten states would be allowed to experiment with benefit design. The goal is to get people better while lowering costs. I don’t know if this will work but it is a reasonable experiment.
Section 302 allows Medicare Advantage firms to apply for waivers to give non-medical benefits to chronically ill patients. Again, I don’t know if this will bend the cost curve and improve outcomes but it is a reasonable thing to try.
Section 303 and 304 and 305 expands telehealth options for Medicare Advantage and Accountable Care Organizations (ACO), and stroke patients. I like that telehealth is not being allowed to count towards network adequacy. The trade-off will be if lower cost visits leads to more visits and more net costs with or without net patient benefit.
Section 401 allows ACO patients to be assigned prospectively. This means the ACO could be chosen by beneficiaries at the start of the year. Attribution is a major challenge and source of technical risk. Retrospective attribution means the ACO is responsible for a population that is only defined after the contract. Prospective attribution allows an ACO to know its patient roster at the start of the contract. This is weedy but useful.
Section 501 allows ACO’s to use member incentive programs for primary care and care coordination purposes. This ties into the same general concept of Section 301 where Congress would like Medicare to make it easier for people to make good choices.
And then there are several sections authorizing the Government Accountability Office (GAO) to conduct studies on interesting questions regarding care coordination.
None of these sections are home runs. There might be a bunt single and perhaps a well hit ball that falls in between the shortstop and the left fielder for a hit. But this is what a decent healthcare focused bill can actually look like. We should encourage this.
NB — we should also encourage a better name for the bill to avoid late night Taco Bell jokes.