NAHC Comments on Senate Finance Committee’s Chronic Care Policy Options: Home Care Comments (Part 1 of 2)
January 29, 2016 09:45 AM
This article summarizes NAHC’s comments on the Senate Finance Committee’s Chronic Care policy options pertaining to home care. The policies under consideration by the Committee affect hospice, home health, palliative care and other providers.A subsequent article will summarize NAHC’s comments on the policies pertaining to hospice.
The National Association for Home Care & Hospice (NAHC) has submitted comments to the U.S. Senate Finance Committee regarding the Chronic Care Working Group’s policy options document titled, the “Bipartisan Chronic Care Working Group Policy Options Document.” As reported in the December 29, 2015, edition of NAHC Report (available here), the Senate Finance Committee released the policy options document in December 2015 after announcing the creation of the Working Group in June 2015. NAHC has been actively engaged in discussions with the Committee on this important issue; for previous coverage of some of NAHC’s activities in this area, please go here, here, and here. Releasing the options document was intended to generate additional comments, feedback, and input from Finance Committee members and stakeholder groups as the Committee works on a more finite list of policy ideas to improve care coordination in the Medicare program.
“We strongly support the direction of the Working Group in considering that caring for individuals with chronic illness in their own homes should be a central aim of any policy reforms,” NAHC stated in its comments submitted to the Senate Finance Committee. “Home care presents the best opportunities to provide high quality care while controlling Medicare spending. It is also a quickly scalable way of coping with the fast-growing population of Medicare beneficiaries as the baby-boomer generation ages.”
With regards to home care, NAHC submitted the following recommendations and comments based on the categories included in the options document:
Expanding the Independence at Home Model
NAHC expressed support for the option of expanding the Independence at Home (IAH) demonstration, and provided specific recommendations for expanding IAH in order to build on its success. Currently, IAH is limited in size and scope. There are only 17 entities in the program, and it is also limited in the Medicare population it serves (only the 5 percent highest risk patients). NAHC stated, “[IAH] has the potential, with design modifications, to serve a greater patient base in an equally effective way. Building on the successes of IAH in expanding both the sites and scope of the model should be a win-win for patients and Medicare.”
NAHC recommended modifying the interdisciplinary team in order to expand the scope of IAH. “While the high risk patients likely need a physician team leader, patients in the lower stratums of risk may not. Accordingly, the team composition and leadership should be flexible, required to be composed in a manner that fits the individual patient.”
The expansion of IAH, NAHC said, should be comprehensive in scope with a schedule that addresses both the number of sites and target populations. With respect to modifying the delivery model, NAHC reiterated its support for a Home-based Chronic Care Management Model, a partnership between home health agencies and patient-centered medical homes that more fully treats the “whole” patient. This model is currently referred to as the “Integrated Care Model” (ICM). “This model would benefit both homebound post-acute patients and pre-acute chronically ill patients,” NAHC said, “while keeping chronically ill patients out of inpatient settings.” The Model would build on IAH in a number of ways, NAHC said, while including a broader focus than IAH, which is limited to the 5 percent of patients most at risk of hospitalization.
Another benefit to the Model is that “advanced technological tools are incorporated into the care management to achieve greater efficiencies, accelerated care actions, and targeted remedial measures.” Furthermore, the model “presents a payment method that fits with the direction of value-based payment and shared risk between provider and payer.” NAHC included a detailed outline of ICM, and cited several successful examples of home care agencies implementing ICM with successful results.
Establishing a One-Time Visit Code Post Initial Diagnosis of Alzheimer’s/Dementia or Other Serious or Life-Threatening Illness
The Committee asked for feedback regarding establishing a one-time visit code post initial diagnosis of Alzheimer’s/Dementia or other serious or life-threatening illnesses, in terms of the scope of diseases that would be considered a serious or life-threatening illness. NAHC stated that “the types of diseases that would fall into the broad category of serious or life threatening are those that are not curable but require medical supervision of at least two visits per year and an ongoing regimen of treatment.” NAHC further stated that “it is best to develop guidelines applicable to all serious and life-threatening illnesses” given the broad scope, rather than developing “criteria for each illness.”
Improving Care Management Services
NAHC recommended the removal of any and all barriers to the use of non-physician practitioners (NPPs) in the care of chronically ill Medicare beneficiaries. “It is the primary care practitioner who is usually managing the care of people afflicted with multiple chronic illnesses,” NAHC said. “Yet, antiquated Medicare policies, borne out of the 1960s, still limit Medicare coverage when the patient’s primary care practitioner is an NPP.” NAHC referenced legislation currently pending in the Senate, S. 578, the Home Health Care Planning Improvement Act of 2015, sponsored by Senators Susan Collins and Chuck Schumer along with a combined total of 42 bipartisan cosponsors.
Telehealth Risk-Sharing Proposal: Reducing Inpatient Care through Technology
NAHC expressed support for the Policy Option to expand the use of telehealth services to better manage the care of patients, reduce hospitalizations, and create cost savings. NAHC recommended two changes to existing Medicare standards. “First, given the Working Group’s commitment to caring for those with chronic illness in their own homes, the ‘originating site’ standard should be revised to include the home. Second, remote monitoring services coverage under Medicare should be extended to care provided by any health care professional.” NAHC also recommended the Committee “consider legislation providing authority to CMS to test the value of care models that rely on the use of telehealth in home care settings.”
Maintaining Flexibility to Provide Supplemental Services in ACOs and any Innovative Model
NAHC recommended that the Working Group support the waiver of the Medicare home health services “confined to home” or homebound requirement in innovative care models such as ACOs, post-acute care bundling, Independence at Home, and the recently initiated Complete Joint Replacement bundle model. “The failure [by CMS] to extend that waiver in these innovative programs limits the intended flexibility that is at the heart of these new models. That flexibility is the chief means by which the innovations can bring about improvements in patient outcomes and spending,” NAHC said.
Encouraging Beneficiary Use of Chronic Care Management Services
NAHC stated that the existing Medicare home health benefit provides an opportunity to broaden the scope and delivery of care management services to chronically ill Medicare beneficiaries. “Part of the problem is the inaccurate assumption that the Medicare home health benefit is a limited, post-acute short term benefit for individuals with an acute condition,” NAHC said. “However, it is one of the best designed benefits in Medicare, permitting coverage of patients with chronic illnesses in a coordinated and comprehensive manner.” NAHC recommended that the Committee “require CMS to engage in nationwide education of its contractors and home health agency personnel focused on this one basis for coverage. If needed, clarifying or expanded policy guidelines should be issued. In the end, an application of this covered service in home care can create the foundation for significant improvement in patient-centered, community-based chronic care management that benefits Medicare beneficiaries and the Medicare program bottom-line.”
Developing Quality Measures for Chronic Conditions
NAHC encouraged the Working Group to use the data collected through Outcome Assessment Information Set (OASIS) assessment tool “as the primary starting point for the new measure development needed to advance any payment reforms.” However, NAHC stated, “we caution that OASIS data is skewed toward patient improvement outcomes that do not universally fit for patients with chronic illness as the goals for those patients may be maintenance or slowed deterioration in their clinical conditions. The Star Rating system totally excludes these types of measures.”
With regards to Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey, NAHC said its “members have reported that there are some limitations associated with the HHCAHPS survey, as a patient’s satisfaction with the care they receive may not reflect the quality of care provided in some instances. Additionally, responses provided by a patient’s friend or family member may not provide a true picture of the care received by the patient as many patients may not share complete details regarding their health condition(s) with others. As such, we believe that HHCAHPS results should be a small component of any system that links payment to quality, if at all.”
Furthermore, NAHC stated that the patient population is “very heterogeneous,” and as such “the use of the same benchmarks or targets may not be appropriate.”
NAHC’s comments are available here.