The Transformation of Chronic Illness Care

By Rich Bringewatt, President and CEO, National Health Policy Group

On February 9, 2018, Congress passed and the President signed into law the Bipartisan Budget Act of 2018. Title III of this legislation contained a series of landmark provisions for advancing the integration of Medicare and Medicaid and for improving care for persons with complex chronic conditions (these provisions are sometimes referred to as the Chronic Care Act of 2018, which was passed by the Senate through unanimous consent and became the foundation for broad consensus). These included:

  • Making Special Needs Plans (SNPs) a permanent part of the Medicare program.
  • Strengthening the role of the Medicare-Medicaid Coordination Office to develop regulations and guidance related to the integration or alignment of policy and oversight for Medicare and Medicaid policy, including unifying grievance and appeals procedures; and
  • Requiring the General Accounting Office (GA0) and MedPAC to conduct several related studies.

These legislative provisions have important implications for improved care for persons with complex needs and for those dually eligible for Medicare and Medicaid. Still, much of the responsibility for systems transformation shifts from Congress to CMS, states, and specialty health plans, particularly for SNPs and Medicare-Medicaid Plans (MMPs). The question is, what’s next? How do we continue to advance care for high-risk/high-need persons? The answers are likely to be a little different for each state and/or plan. But four considerations will be critical for maintaining if not accelerating progress.

1. Shared vision.

Problems of chronic disease and disability are multi-dimensional, interdependent, personal, volatile, and ongoing. Many of the people with these conditions require support from both Medicare and Medicaid programs. Optimizing quality and cost performance requires us to transform the full spectrum of clinical, administrative, and regulatory functions in accordance with the core nature of the problem to be addressed.

The signing of this bill is of little relevance unless we—the caregivers and gatekeepers, policy wonks and industry leaders—embody these advances and allow them to embolden our vision. If we want to have meaningful dialogue about system transformation, we need to focus on our goals for the future, rather than argue over where we’ve been or where we are or are not now. We must not only have clarity of vision; everyone involved must be pulling together in a common direction.

This requires SNPs, MMPs, and other plans and providers specializing in complex care to move beyond advancing comprehensive care management functions. Plans, policymakers and care providers must move beyond improving care transitions between hospitals and related care providers, to establishing care systems where all care providers who serve many of the same people work together around a common plan as a person’s chronic condition evolves over time and across care settings. It requires CMS and state Medicaid agencies to move beyond allowing for joint contracting for Medicare and Medicaid benefits and services, to enabling SNPs, MMPs, and other specialty plans with joint Medicare and Medicaid authority to work under policies and procedures where all methods and policies are fully aligned. This alignment should include payment and enrollment methods, models of care requirements, marketing and member communications, performance metrics and methods, appeals and grievance procedures, and state and federal oversight methods.

2. Think systems.

Chronic disease and disability are systems problems and require systems solutions. Seventy-one percent of health care spending is for patients with multiple chronic conditions. Thirty-five percent of spending is for the 8.7 percent of people with five or more chronic conditions. Twenty-eight percent of Medicare beneficiaries with five or more chronic conditions are dually eligible for Medicare and Medicaid.[1] Multiple funding sources, physicians, pharmacies, and care providers are involved for EVERY complex care beneficiary. These entities include specialty clinics, nursing homes, and the full array of home community service programs.

We—policymakers, plans, and care providers—will not significantly reduce costs or improve care outcomes for these complex care beneficiaries unless we move beyond tweaking individual program functions and care components to simplifying the patterns of behavior among related care providers. We can create interdisciplinary care teams for improving care-planning functions, but holistic care for chronically ill persons will not become a reality as long as all the providers involved in a person’s care are incentivized to restrict their caretaking to the confines of their own profession or agency. Unless plans, providers, and policymakers shift our focus, we are just putting band-aids on a broken system.

Health plans responsible for all Medicare and Medicaid beneficiaries cannot achieve administrative efficiencies unless CMS and states fully align program requirements and related oversight functions. Plans cannot optimize total cost performance as long as provider contracts exclude accountability for accumulation of costs among related providers and their evolution of care outcomes and related costs over time. Plans and providers cannot optimize total quality performance for people with multiple, complex care needs until CMS and states abandon their obsession with micro-managing performance through the monitoring of specific interventions, for specific illnesses, at specific points in time. Instead, they must account for the dynamic, systemic, and ongoing nature of chronic illness. Our nation will not see significant and enduring improvement in care of dually eligible beneficiaries until plans, providers and policymakers think about chronic illness care as something more than a set of finely tuned but separately defined Medicare and Medicaid benefits and services.

3. Be transformative.  

Over the last several years, CMS has made a number of changes in payment methods, performance metrics, and oversight structures that have helped to improve care for complex care beneficiaries. However, a number of market forces continue to impede progress. Some plans are abandoning SNPs and MMPs because they see a financial advantage in characterizing themselves as “SNP look-a-like” without doing what is necessary to actually integrate benefits and services or re-engineer care and oversight commensurate with the complex care needs of their enrollees. Some states and plans are establishing LTSS programs under state Medicaid funding, absent any real plans to align those efforts with related Medicare benefits and services. CMS has taken steps to recognize selected social and environmental factors influencing the Star Rating System (the system CMS uses to measure how well Medicare Advantage and Part D plans perform); however, the methods fail miserably in fully accounting for how social determinants of health influence care outcomes.

Effective system transformation requires policymakers to change the nature of market forces to advance rather than hinder progress in chronic illness care. It requires CMS and states to modify program requirements, simplify processes and procedures, and do whatever possible to keep the march of fundamental systems transformation for complex care beneficiaries moving forward.

4. Focus on high-leverage interventions.

Chronic illness care is complicated. The level of change necessary to make the status quo a more efficient and effective system can be overwhelming. Effective transformation of our care system requires focus. Small changes can produce major results if properly calibrated.

To nudge our health care system to move in the right direction requires us—plans, providers, researchers, and policymakers—to understand more fully all the major forces at play, to look more closely at patterns and structures of behavior within our health care system rather than obsess over the detailed functionality of every isolated program or function, absent their relationship to other related programs and functions.

The devil is always in details. Focusing on the right detail can move mountains.

Experience would suggest that the mental maps and value structures that plans, providers, and policymakers use in their thinking, along with the organizational incentives contained in professional and program certification, payment methods, performance metrics and methods, and the bifurcation of administrative arrangements embedded in the Medicare and Medicaid, programs drive much of health care’s current behavior. System theory would suggest that if we change these incentives to take into account the systemic nature of chronic disease and disability, we could succeed in improving quality and cost outcomes for people with complex care needs.

Virtually everyone involved in advancing complex care—consumers, plans, provider and professional associations, academia, foundations, think-tank and policy centers, legislators and regulators—seems to agree on many of the core principles of effective care. Over the years, Congress, CMS, plans and providers have made important progress in advancing program integration and improving care of people with complex care needs. Yet we have a long way to go.

The greatest threat to further progress is not from a failure of smart, caring people to think right but from the insidious nature of people, culture, and care systems to continue to do what they have always done. The danger is that plans, providers, and policymakers will be more comfortable with what is than what could be. We know better; we can do better.

As Ken Blanchard, once said, “None of us is as smart as all of us.” In the words of Margaret Mead, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has. Now is not the time to sit back and celebrate our progress but to get on with the task at hand.