C-TACPolicyWebinar:Policy OpportunitiestoImprove

AdvancedIllnessCare

MarianGrantAndrewMacPhersonSeptember6,2017

Objectives

• Updateparticipantsonhealthcareandadvancedillnesspolicyenvironment• Reviewregulatorybarriers/opportunitiesforadvancedillnesscare• Reviewlegislativebarriers/opportunitiesforadvancedillnesscare

HealthCareAndAdvancedIllnessPolicyEnvironment

PolicyandPoliticalEnvironmentforHealthCare• ApprovalofCongresspollingbelowfunthingslikerootcanals,trafficjams,andcockroaches…• TheapprovalratingofCongressaccordingtoarecentpollishoveringaround17%• Presidentialdisapprovalratingcreepingupbytheday(hour?)– quicklylosingimportantpoliticalcapital• “RepealandReplace”Context:Campaignpromises– HowmuchdoRepublicanshavetodo?• FutureofRepublicanhealthreformeffortsuncertain,butnotdeadyet

PolicyandPoliticalEnvironmentforAdvancedIllnessCare• Advancedillnesspopulationdirectlyunaffectedbyrepeal/replaceefforts,withsomeexception• DespitepoliticaltoxicityimportantreformsbeingpursuedatCMSandonabipartisanbasisinCongress• MultipleC-TACpolicyinitiativesproceedingapacedespitepoliticalheadwinds

RegulatoryBarriers/OpportunitiesForAdvancedIllnessCare

RegulatoryBarriers

• Payment• Regulatorystructures• MedicareHospicebenefit• Interdisciplinaryteamrestrictions

PaymentBarriers

• Fee-for-servicedoesnotsupportdeliveryofhigh-qualitycommunity-basedcareforadvancedillness• Newalternatepaymentmodelsforadvancedillnessnotyetavailable• CTACPTACproposal

AlternatePaymentModel

• C-TACwillhaveAdvancedCareModelreviewedbyHHSPTACon9/7• Paysfor• Interdisciplinarycareteam• Careathome• 24/7access

• https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee

OutmodedRegulatoryStructures

• MedicareConditionsofParticipation(CoPs)forhomehealthandhospiceagenciesimpededeliveryofcoordinatedservicesathome.• Waiversareshort-termoption• Long-term,eitherneedflexibilityaroundCoPs ornewdesignationforhome-basedadvancedillnesscare

MedicareHospiceBenefitBarriers

• Restrictiveeligibilityrequirementscauselateormissedhospiceadmission• CMSmayrevisebasedonMedicareCareChoicesDemonstrationmodel• Advancedillnesscaremodelscanaddresspre-hospicegap

InterdisciplinaryTeamRestrictions

• Fee-For-Servicedoesn’tpayforallteammembers• Newadvancedpaymentmodelswillresolve• Staterestrictionsonabilityofsometeammemberstopracticeattopoflicense

OtherRegulatoryOpportunities

• Monitorregulations• Waystoimproveadvancedcare• Maintainimportantelements

• Advocacywhencommentingonproposedrules• ProposalstoCMSforadvancedillness

C-TACRegulatoryAreas

• Paymentmodels• CommittedPartner,HealthcarePaymentLearningandActionNetwork(LAN)• Regulatorytaskforce• Reviewandcommentonproposedrules• Coordinatewithqualitymeasureswork• Specialprojects

KeyRegulatoryRules

• MACRAQualityPaymentProgram• PhysicianFeeSchedule• MedicareAdvantage• HospiceQualityandPayment• Others• Endstage RenalDisease(ESRD)qualityprogram• SNF,Outpatienthospitals,HomeHealth

C-TACMACRAComments

• Addproposedadvancecareplanningimprovementactivity,increaseweightfrommediumtohigh• Reviserequirementforcognitiveassessmenttoincludeseriousdementiaand/orpalliativecare• Provideshort-termbonustoproviderscaringforpeoplewithcomplexillnessandsocialriskfactors• Allowprovidersoptiontoweightcostcategoryat10%in2018• Implementproposedvirtualgroup

C-TACESRDComments

• IncludeAcutekidneyinjury(AKI)populationinESRDprogram’squalitymeasurement.• FutureAKImeasuresshouldpromoteadvancecareplanning,integrateadvancedillnessmanagement/palliativecare• IncludeaccountingforSocialRiskFactors• RequestforInformation(RFI)onWaystoImproveMedicare- Promoteintegrationofadvancedillnessmanagement/palliativecareforthispopulation

LegislativeBarriers/OpportunitiesForAdvancedIllnessCare

LegislativePriorities

• C-TAChasbeenworkingwithalliesontheHilltodeveloppoliciesthatwilleliminatebarrierstohighquality,person-centeredcare• Manyofthesebillshavereceivedbipartisan,bicameralsupportinCongress,including…

ThePatientChoiceandQualityCareAct(PCQCA)of2017

• Sponsoredby:• Representatives EarlBlumenauer [D-OR],DavidRoe [R-TN],TomO'Halleran [D-AZ],Gregg Harper[R-MS],RonKind [D-WI]DavidYoung[R-IA],JohnDuncanJr.[R-TN],Andre Carson[D-IN],JamieRaskin [D-MD],CarolShea-Porter[D-NH],JamesMcGovern [D-MA],EarlL."Buddy"Carter[R-GA],SusanCollins[R-ME]

• SenatorsMarkWarner[D-VA],JohnnyIsakson[R-GA],TammyBaldwin[D-WI],AmyKlobuchar[D-MN],ShelleyMooreCapito[R-WV]

• Introduced:June14,2017• ReferredtoSenateCommitteeonFinance• ReferredtoHouseCommitteesonEnergyandCommerceandWaysandMeans

ThePatientChoiceandQualityCareAct(PCQCA)of2017

• CreatesanewMedicaremodelforAdvancedIllnessCareandManagement• Individualscanvoluntarilyengageinteam-basedcareplanning

• Facilitatesincreasedcoordinationandalignmentbetweenpublicandprivatesectorqualitymeasures.

• ImprovesMedicare’sexistingcoverageforadvancecareplanning(ACP)servicesbyallowingappropriatelytrainedorexperiencedclinicalsocialworkerstoprovideACPservices,andensuringcopaycostsnotbarriertopatients.

• Ensurespatientsandprovidershaveneededsupporttoolsandthatadvancedirectivesfollowpatientacrossclinicalsettingsandstates

• Requireshealthcarefacilitiesassurecareplansmadewhileindividualreceivescareappropriatelydocumentedpriortodischargeandsenttoappropriateprovidersandfacilitiesupondischarge.

• Funds$50millioningrantstoincreasepublicawarenessofACPandadvanced

CreatingHigh-QualityResultsandOutcomesNecessarytoImproveChronic(CHRONIC)CareAct

• Sponsoredby:• SenatorsOrrinHatch[R-UT],RonWyden [D-OR],JohnnyIsakson [R-GA],MarkWarner[D-VA],MichaelBennet [D-CO],BenCardin [D-MD],JohnThune[R-SD],BobCasey[D-PA],JohnCornyn [R-TX],MikeCrapo [R-ID],ChuckGrassley [R-IA],ThomasCarper [D-DE],DebbieStabenow [D-MI],ClaireMcCaskill [D-MO],PatRoberts[R-KS],BillCassidy[R-LA],RogerWicker [R-MS],BillNelson[D-FL],BrianSchatz [D-HI]

• Introduced:April6,2017• ReportedoutoftheSenateCommitteeonFinanceonAugust3,2017andplacedonlegislativecalendar

CreatingHigh-QualityResultsandOutcomesNecessarytoImproveChronic(CHRONIC)CareAct

• ExtendsIndependenceatHomedemonstrationby2years.• ExpandstestingofMAValue-BasedInsuranceDesigntestmodel.• AllowsMAtoprovideadditionaltelehealthbenefitstoenrolleesand,tochronicallyillenrollees,certainsupplementalhealthcarebenefits.

• Allowsprospective,voluntaryassignmentofMedicarefee-for-servicebeneficiariestoaccountablecareorganizations(ACOs),and

• AllowsACOstooperatebeneficiaryincentiveprograms.

RemovingBarrierstoperson-CenteredCareActof2016

• Sponsoredby:• SenatorsSheldonWhitehouse[D-RI]andElizabethWarren[D-MA]

• Introduced:June23,2016• ReferredtoSenateCommitteeonFinance• HearingsheldbeforetheSenateSpecialCommitteeonAging

RemovingBarrierstoperson-CenteredCareActof2016

• AmendstitleXI(GeneralProvisions)oftheSocialSecurityActtoestablishanalternativepaymentmodelforpatient-centeredcarewithrespecttoMedicarebeneficiarieswithadvancedillnesses.• Throughthevoluntarypilotprogram,theCentersforMedicare&MedicaidServices(CMS)shallenterintodemonstrationprojectagreementswithadvancecarecollaborativestoprovidehighqualityMedicareservices.

CompassionateCareAct

• Sponsoredby:• SenatorsRichardBlumenthal[D-CT]andShelleyMooreCapito[R-WV]

• Introduced:May19,2016• ReferredtoSenateCommitteeonHealth,Education,Labor,andPensions

• RequirestheCentersforDiseaseControlandPreventiontodevelopandimplementanationalcampaignthatinformsthepublicoftheimportanceofendoflifecareoradvancedcareplanningandofanindividual'srighttodirectandparticipateinhealthcaredecisions.

CompassionateCareAct

IndependenceatHomeActof2017

• Sponsoredby:• SenatorsEdMarkey[D-MA],RobPortman[R-OH],MichaelBennet[D-CO],JohnCornyn [R-TX],AngusKing[I-ME],SherrodBrown[D-OH],BillCassidy[R-LA],KirstenGillibrand[D-NY]

• Introduced:February28,2017• ReferredtoSenateCommitteeonFinance

IndependenceatHomeActof2017

• ExpandsIndependenceatHomedemonstrationprogramtoanationwidebenefit• ProvideseligibleMedicarebeneficiarieswith24/7,home-basedprimarycarebyaninterdisciplinaryteamofproviders.

• Advancesourgoaltoshiftofcareoutofhospitalandintocommunities

PalliativeCareandHospiceEducationandTraining(PCHETA)• Sponsoredby:• 160+sponsoringMembers inthe House ofRepresentatives;94Democrats,66Republicans• SenatorsTammyBaldwin[D-WI],ShelleyMooreCapito[R-WV],SusanCollins[R-ME],AngusKing[I-ME],ChrisCoons[D-DE],LisaMurkowski[R-AK],ChrisMurphy[D-CT]JerryMoran[R-KS],JohnBoozman [R-AR],KirstenGillibrand[D-NY]

• Introduced:March22,2017• ReferredtoSenateCommitteeonHealth,Education,Labor,andPensions• ReferredtoHouseCommitteeonEnergyandCommerce

PalliativeCareandHospiceEducationandTraining(PCHETA)• Focusesonworkforcedevelopmentforadvancedillnesspopulation• Fosterspalliativecareandhospiceeducationcenters.• Establishesnationalcampaigntoinformpatients,families,andhealthprofessionalsaboutpalliativecarebenefitsandservices• DirectsNIHtoexpandnationalresearchtoimprovedeliveryofpalliativecaretopatientswithseriousillness.

…EndofLifePolicyMakingNews

• Axios,September5:• “AbipartisancoalitionofformerHHSofficialsandformersenators ispushingCongresstopassabillthatencouragesMedicarebeneficiariestopreparedigitaladvancecareplans…The[MedicareChoicesandEmpowermentAct],sponsoredbyDemocraticSen.ChrisCoonsandRepublicanRep.DianeBlack,wouldgivethemasmallpayment($75iftheyregisterthisyear)tofileaplanoutliningwhatmedicalcaretheywant,andwhattheydon'twant,inanemergencywheretheycan'texpresstheirwishes.”

Q&AandClosingThoughts