Recommendations On Policy Options/Transforming the Health Care Delivery System

Section I: Payment Reform - Options to Improve the Quality and Integrity of Medicare Payment Systems

Linking Payment to Quality Outcomes

The National Committee to Preserve Social Security and Medicare believes that provider reimbursement should be aligned with quality improvement. In general, the value-based purchasing policy options described in the Policy Options document offer promising approaches to employing financial leverage to enhance quality.

It is important that payment penalties be considered in addition to modest bonuses. In addition, it is important that value-based purchasing be balanced: not spending too much on bonuses or harming access by implementing policies that discourage provider participation.

We also recommend that the selection of quality measures be a dynamic process. These measures must relate directly to the improvement of patient care processes, and they must be changed over time to challenge providers to attain higher performance levels. There is a danger that the selection of measures for value-based purchasing will become politicized, resulting in "dumbed down" measures with little leverage to improve care processes. It is important that the Department of Health and Human Services (HHS) be given the authority to establish meaningful quality measures.

Primary Care

Payment for Transitional Care Activities

 The National Committee strongly supports the inclusion of reimbursement for chronic care management services. While oversight of such services by a physician is appropriate, it would be advantageous to allow providers such as community health teams to bill Medicare directly for these services. It is also important to ensure that qualified non-physician practitioners may play a prominent role in providing these services.

It is important that reimbursement apply only to high-quality, cost-effective services. Required activities should be specified in statute, and should include a formal assessment, care plan, ongoing evaluation, and self-management support.

It is useful for coverage of these services to begin with the six chronic disease areas specified in the Finance Committee's proposal. However, it will be important to extend coverage to include other chronic diseases, and HHS should be given authority to do so after a period of five years.

Section II: Long-Term Payment Reforms – Options to Foster Care Coordination and Provider Collaboration 

Moving from Fee-for-Service to Payment for Accountable Care

Medicare Shared Savings Program

We support efforts to employ models such as Accountable Care Organizations to increase efficiency in the Medicare program and to allow providers to share the savings. We agree with the criteria for provider participation listed in the Finance Committee's proposal, and suggest that they be specified in statute.

It also will be important to create a means of ensuring that all providers receive an adequate portion of the savings if only one provider (such as a hospital) receives payment on behalf of a group of providers. It is important to charge HHS with enforcement responsibility to address this issue.

Quality indicators should relate directly to improving care processes. It is important that any tendency to set these indicators too low be addressed through a dynamic selection process. HHS should be charged with reviewing and changing these indicators on a regular basis to reflect advances in quality improvement. 

Section III: Health Care Infrastructure Investments - Tools to Support Delivery System Reform

Health IT

We believe that eligibility for EHR Medicare incentive payments should be extended to nurse practitioners and physician assistants providing services in underserved areas. In addition, such incentives should be extended to providers such as community health teams that deliver chronic care management services. 

Comparative Effectiveness Research 

The National Committee supports the Finance Committee's consideration of "options to establish a long-term or permanent framework to set national priorities for comparative clinical effectiveness research and to provide for the conduct of such research." Comparative effectiveness research has the potential to improve the quality of care patients receive while at the same time slowing the rate of increase in health care spending. We support an expanded investment in comparative effectiveness research, with funding coming from general revenues, the Medicare Trust Funds, and assessments on private insurance; and we agree that this investment is needed now because it will take time to achieve results that can provide helpful information to providers and their patients. Also, we stress the importance of including older Americans in the comparative research that is undertaken.

Transparency 

Physician Payment Sunshine 

The National Committee strongly supports a requirement that drug and medical device manufacturers make annual public reports of their gifts and payments to physicians and other parties. We believe that nurse practitioners, pharmacists, hospitals, medical associations, and patient/disease groups should also be required to report - as has been suggested by Medicare Payment Advisory Commission and the Institute of Medicine . Any de minimus threshold for the reporting of individual payments should not be lower than $10. We do not believe that any manufacturer should be exempted. (If the "small" companies have the resources to obtain Food and Drug Administration approval for sale of their drugs or devices, they possess adequate resources to meet this requirement.) It is important that reported information be made available on the internet in a searchable format easily used by the public.

Section IV: Medicare Advantage - Options to Promote Quality, Efficiency and Care Management 

Developing a More Efficient Payment Structure 

A top priority for the National Committee to Preserve Social Security and Medicare is leveling the playing field between traditional Medicare and private Medicare Advantage plans. We are pleased that the Finance Committee is looking at proposals to reduce the overpayments to Medicare Advantage plans, which are increasing costs for the Medicare program and all Medicare beneficiaries whether or not they enroll in a private plan.

Approach 1: Modify Current Benchmarks

In addition to your suggested approach for modifying current benchmarks by blending local and national fee-for-service spending, we believe it is important to consider the approach in the Congressional Budget Office's Option 63, "Set the Benchmark for Private Plans in Medicare Equal to Local Per Capita Fee-for-Service Spending." We support neutrality between what is spent per beneficiary whether they enroll in traditional Medicare or a private Medicare Advantage plan. In addition, it is likely that this approach will benefit plans serving low-income and minority populations and will require plans to provide care coordination that improves the quality of care and reduces spending on otherwise unnecessary services.

Approach 2: Set Benchmarks Based on Plan Bids 

The National Committee has significant concerns about the approach of setting benchmarks based on plan bids. It is unclear how plans would react to this approach or how their bids would differ from what they are currently, and we question how competitive the bidding would be given that the majority of Medicare Advantage enrollees in each county are in very few plans. Also, it appears that it would be difficult for CMS to administer such a program. A further concern is that competitive bidding would be less advantageous to urban counties serving low-income and minority populations than the 100 percent fee-for-service approach.

Pay for Chronic Care Management

The National Committee believes that enhanced care coordination for Medicare beneficiaries with chronic conditions is very important and supports adding a chronic care coordination benefit in traditional Medicare that will help older adults with complex chronic conditions, disabilities, or dementia. However, it is our understanding that one of the selling points for private Medicare Advantage plans, most of which are coordinated care plans, is that these plans coordinate care for beneficiaries. Therefore, we are opposed to singling out private plans to receive bonus payments for providing chronic care management. It is our understanding that this is something good plans were doing before receiving overpayments, are doing today, and likely will continue to do when overpayments are eliminated.

Simplify Extra Benefits

The National Committee supports the Finance Committee's proposals to simplify extra benefits that are paid for by the Medicare program through overpayments that only help enrollees in private Medicare Advantage plans. We are concerned that given the confusing array of choices, it is extremely difficult for beneficiaries to assess which plans offer the best value, and we are concerned that some plans impose excessive cost-sharing for beneficiaries needing coverage for serious conditions. We support limiting cost sharing to the amount that applies in traditional Medicare for Parts A and B services, and oppose cost sharing for services such as home health, especially since people often do not realize the differences in benefits until they need certain services. In the case of home health, this is an important benefit which enables people to remain in their homes and communities and can save money by reducing the need for nursing home and hospital care. It is important to standardize and simplify benefit offerings so beneficiaries understand what they are choosing and so cost-sharing requirements do not discriminate against beneficiaries needing certain kinds of treatments.

Section V: Public Program Integrity - Options to Combat Fraud, Waste and Abuse

Provider Screening

We strongly support the use of screenings prior to the acceptance of provider and supplier applications for Medicare billing privileges. However, it is important that some of the described screening requirements - such as the submission of fingerprints and unannounced site visits - be applied selectively based on an assessment of risk. It is important that such requirements not be onerous for the bulk of applicants, to avoid the risk that provider participation in Medicare would be substantially reduced, harming access for beneficiaries. Similarly, application fees assessed to pay for screening should not discourage participation.

We also support the use of improved databases to identify and prosecute fraudulent activity.

Thank you for providing this opportunity to provide our views on these important components of health care reform.

Government Relations and Policy, May 2009