Doctors Supportive of Chronic Care Recommendations With Changes

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By Mindy Yochelson

Feb. 3 — The American Medical Association offered strong support for various options presented by a Senate committee for improving the care of Medicare beneficiaries with chronic illnesses but cautioned against the CMS adding measures for grading doctors on the outcomes for beneficiaries with chronic diseases.

“We agree that it is important to have valid and reliable quality measures for treating patients with chronic conditions,” the AMA said in a late January letter to the Senate Finance Committee. “However, we have significant concerns with establishing new statutory requirements to create measures that target chronic conditions or holding providers accountable under new measures.”

Feedback on Document

The AMA's letter was among those from physician groups sent to the committee's Chronic Care Working Group. The committee received comments from associations representing a variety of health-care sectors.

The associations offered feedback on the working group's Dec. 18 Bipartisan Chronic Care Working Group Policy Option Document.

The document outlined a number of suggestions for improving how Medicare treats beneficiaries with multiple chronic conditions.

Among the topics discussed were expanding independence at home programs, coverage of behavioral health, supplemental benefits and use of telehealth, as well as making changes to Medicare Advantage and accountable care organizations.

Comments were due Jan. 29.

The working group said it will use the input toward producing a bipartisan measure that can be advanced through the Finance Committee.

Modifications Recommended

The doctor groups mostly expressed enthusiasm for the recommendations while suggesting a few modifications.

On one recommendation, the committee said that it's considering requiring that the Centers for Medicare & Medicaid Services include in its development of quality measures for doctors those that focus on the health-care outcomes for individuals with chronic disease.

“The current quality measurement landscape does not have sufficient measures that can be used to monitor the quality of care for individuals with multiple chronic conditions,” the paper said.

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the CMS is developing measures under a physician quality grading program—the Merit-based Incentive Payment System (MIPS)—that will affect providers' reimbursements starting in 2019.

The AMA objected to the suggested health outcome addition, stating that it takes substantial time and resources to develop new quality measures and appropriately test and evaluate them to ensure they are valid and reliable.

“We believe it would be unwise and premature to add additional requirements for measure development until CMS has been given a chance to conduct a thorough review of what measures are needed,” the AMA said. “Imposing new requirements at this stage would disrupt the MIPS measure development process and could lead to unintended consequences and unforeseen distortions.”

Special Needs Plans

Like the AMA, the American College of Physicians (ACP), which represents mostly internal medicine doctors, strongly supported the recommendations but wanted some change.

The paper had urged long-term extension or a permanent authorization of Medicare Advantage (managed care) special needs plans (SNPs), which target three types of enrollees. SNPs have been subject to a series of short-term congressional authorizations.

The working group wanted feedback on what modifications should be made to one of the three types of SNPs—those for the chronically ill (C-SNPs).

“A long term extension of SNPs would allow for greater planning of and investment in successful care models that SNPs provide to these vulnerable beneficiaries,” the document said. “Congress’s current pattern of short-term extensions limits the use and growth of SNPs.”

Limited Enrollment

The ACP said that, while “C-SNP plans are available in the Medicare Advantage (MA) benefit for certain chronic conditions, only about 300,000 beneficiaries were enrolled in them as of April 2015, representing only 2 percent of total MA enrollment.”

The ACP said it prefers a broader approach to SNPs, as had been recommended by the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare issues.

In 2013, MedPAC recommended a moratorium on new C-SNPs and instead suggested that MA plans include benefits that vary based on individuals' medical needs. The C-SNP model of care could be housed within a regular MA plan, rather than operate as a separate plan and MA plans could then tailor benefit packages for chronic or disabling conditions.

The ACP said that since most Medicare beneficiaries have chronic conditions, it supports MedPAC's stance of expanding the flexibility of MA plans to tailor their benefits to meet the specific health-care needs of the beneficiary. “In effect, this approach folds into the general MA program aspects of current C-SNP.”

More Codes for Visits

Another group, the American Academy of Family Physicians, generally supported the recommendations but objected to one for the addition of codes that would allow doctors to bill for a one-time visit following a diagnosis of a serious illness.

The document said the one-time payment would be for clinicians to talk to beneficiaries about the “progression of the disease, treatment options, and availability of other resources that could reduce the patient’s health risks and promote self-management.”

The AAFP discouraged adding more Medicare evaluation and management codes with specific documentation requirements.

Patients benefit from a whole-person approach, the group said. They aren't “simply a collection of conditions or diseases.”

New E&M codes would “be a nightmare, particularly for primary care physicians who offer comprehensive care covering multiple serious and life-threatening conditions, which often occur simultaneously in the patient.”

Instead, the committee should move away from under-valued fee-for-service codes to a model in which primary care is paid globally, the AAFP said.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Janey Cohen at