Introduction

With more than three-quarters of Medicare beneficiaries having at least one chronic condition that requires ongoing medical management, access to medical services is critical. The Center for Medicare Advocacy has been working, through research and analysis of the law and through the development of recommendations to improve the Medicare benefit package, to assure that people with chronic conditions receive the care they need. The findings of the Center will help advocates analyze the effectiveness of programs for people with chronic conditions that were included in the Medicare Act of 2003, Public Law 108-173 (December 2003).

Access to Therapy Services

People with chronic conditions who rely on Medicare often require physical, occupational, and speech therapy. Although these individuals may not be expected to improve, they nonetheless require therapy to slow the progression of their deterioration or to maintain their current functional level.

Nevertheless, people with chronic conditions are often denied Medicare coverage for therapy services. A major barrier is that the Medicare contractors that review Medicare claims rely on Medicare policy manuals and local coverage determinations that are more stringent than the statutory standards. These contractors often incorporate into the medical necessity requirement an improvement standard not present in the Medicare statute or regulations. Thus, the contractors often deny legitimate Medicare claims as not being reasonable and necessary.

A paper developed by the Center for Medicare Advocacy (commissioned by Johns Hopkins University), entitled "Medicare Coverage of Therapy Services: Are the Interests of Beneficiaries With Chronic Conditions Being Met," identifies barriers to Medicare coverage for beneficiaries with chronic conditions and reviews standards for such coverage. The paper (available HERE) urges that all language be made consistent with the Medicare statute, regulations, and case law, thereby establishing a consistent, fair approach to covering medically appropriate therapy for people with chronic conditions.

Coordinated Care

People with chronic conditions also require coordination of the services they need to avoid fragmentation of care and to assure that all of their health care needs are met. Based on the recommendations of a wide array of experts brought together by the Center for Medicare Advocacy at a conference supported by the Commonwealth Fund, the Center developed recommendations for a coordinated care benefit to be incorporated into the traditional Medicare program. The recommendations include:

• The primary, over-arching goal of a Medicare Coordinated Care Benefit should be to improve care.

• Savings should not be the goal of a Medicare Coordinated Care Benefit.
  

• The Benefit should recognize a focus of empowering the beneficiary.
  

• Eligibility should be based on:

• The individual having 5 chronic conditions, or

• A combination of clinically complex chronic conditions which would be amenable to coordinated care, or;

• Two or more chronic conditions and functional impairments which limit the ability of the individual to manage those conditions.

• The Benefit should consist of two areas of coordination:

• Coordination among the beneficiary’s doctors about clinical/medical components of care, performed by medical personnel under the supervision of a physician;

• Coordination of related health and social services, performed by a care coordinator.

To view the complete list of recommendations, click HERE.

Medicare Act of 2003

The Medicare Act of 2003 requires the phased-in development of a chronic care improvement (CCI) program as part of the traditional Medicare program. Under Phase I of the program, the Centers for Medicare & Medicaid Services (CMS) will contract with organizations to offer self-care guidance and support to approximately 150,000-300,000 people with specified chronic conditions in 10 regions of the country over a three year period. Organizations interested in operating a CCI program must submit their proposals to CMS by August 6, 2004. 69 Fed. Reg. 22065 (April 23, 2004).

CMS has limited the initial CCI programs to people with congestive heart failure (CHF), complex diabetes, or chronic obstructive pulmonary disease (COPD) because people with these conditions account for a disproportionate amount of Medicare expenditures. CMS will identify individuals with these conditions in the regions in which CCI programs will operate and advise them of the programs; participation will be voluntary. The programs are supposed to provide beneficiaries with self-care guidance and support in managing their physicians’ plans of care for all health problems, as well as to provide physicians with relevant clinical information to increase reliance on evidence-based care.

Beneficiaries will not have to pay for the services; each organization chosen to operate a CCI program will be paid a monthly fee based on the number of participants. CMS will review each program by standards that it establishes, including savings to the Medicare program. Organizations that do not meet these standards will have to refund all or part of the fee they are paid under the program.

Questions to Ask

As advocates monitor the effectiveness of phase I of the CCI programs, they should consider the following questions:

• Will the information provided to beneficiaries as part of their self-care guidance be limited to information specific to the treatment protocols for CHF, diabetes, and COPD, or will it include information about treatment protocols for other chronic conditions that participants have?
  

• Will the self-care guidance address issues of access to care, such as the availability of therapy services for people who need therapy to maintain functioning or to prevent deterioration?
  

• Will the organizations coordinate the care and services ordered by the various physicians treating each participant, or will their communications with physicians be limited to providing clinical information about evidence-based care?
  

• Will the organizations coordinate other non-medical services, such as transportation and social workers?
  

• What action will the organizations take if a participant is not capable of self-management, even after the organization provides patient education?
  

• What standards will be used to measure quality? Will CMS look to health outcomes and patient satisfaction in addition to cost savings to the Medicare program? How will improved health outcomes and patient satisfaction be measured?
  

• After the initial phase, what efforts will CMS and Congress take to incorporate into traditional Medicare a chronic care benefit that is available to all beneficiaries, regardless of diagnosis?

Conclusion

The Chronic Care Improvement pilot program is a small step toward providing Medicare beneficiaries with the health care they need. However, CMS and Congress could more successfully improve the Medicare program and access to important care for people with chronic conditions by

• Assuring that the existing statute and regulations are properly applied so that people are not denied access to Medicare-covered services for which they are eligible; and
  

• Adding a coordinated care benefit to traditional Medicare that is available to all beneficiaries with chronic conditions, and not just those conditions that are the most costly to the Medicare program.