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May 12, 2017
Dear Chairman Hatch & Ranking Member Wyden:
I write today to offer the National Coalition on Health Care’s support for key provisions of S. 870, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, and to suggest steps to further strengthen the legislation as it moves forward.
NCHC is the nation’s largest, most broadly representative nonpartisan alliance of organizations focused on health care. The Coalition is committed to advancing—through research and analysis, education, outreach, and informed advocacy—an affordable, high-value health care system for patients and consumers, employers and other payers, and taxpayers. Our members and supporters include nearly 90 of America’s largest and leading associations of health care providers, businesses and unions, consumer and patient advocacy groups, pension and health funds, religious denominations, and health plans. Our member organizations represent—as employees, members, congregants, or volunteers—more than 150 million Americans.
NCHC applauds the introduction of this legislation and commends your efforts on chronic care, an issue that is vital to affordability in Medicare and across our health care system. We are pleased to support the following provisions:
- Section 201, Providing Continued Access to Medicare Advantage (MA) Special Needs Plans for Vulnerable Populations: MA Special Needs Plans have served as incubators for promising delivery and benefit innovations, enabling plans to develop new ways of managing chronic disease and coordinating care for some of the sickest Medicare enrollees. This important provision ensures that they can continue to play that role.
- Section 301, Adapting Benefits to Meet the Needs of Chronically Ill Medicare Advantage Enrollees: NCHC supports the expansion of the MA VBID demonstration to all fifty states and U.S. territories. As currently implemented, this demonstration includes important beneficiary protections, including the requirement that cost-sharing is reduced rather than increased and uniform notice requirements. The national expansion of this model test can better inform the development of future reforms to align benefit structures with ongoing value-based provider-payment reforms and lower cost barriers to needed care.
- Section 302, Expanding Supplemental Benefits to Meet the Needs of Chronically Ill Medicare Advantage Enrollees: This important provision will ensure plans can deploy services that may not be covered under Medicare but can improve health outcomes and lower costs. Examples of such services should include, but need not be limited to, non-covered transportation, nutrition, in-home support services, behavioral health services, palliative care services, home improvement, communication devices, caregiver training and support, assistive devices, and remote patient monitoring systems.
- Telehealth Provisions: Certain telehealth provisions of the CHRONIC Care Act are consistent with NCHC-supported telehealth legislation—the CONNECT for Health Act (S. 1060). We are pleased to support the following provisions:
o Section 102, Expanding Access to Home Dialysis Therapy
o Section 304, Providing Accountable Care Organizations the Ability to Expand the Use of Telehealth
o Section 305, Expanding Use of Telehealth for Individuals with Stroke
- Section 401, Providing Flexibility for Beneficiaries to be Part of an ACO: This provision makes needed improvements to the Medicare Shared Savings Program, including the option to assign beneficiaries to ACOs prospectively in all MSSP tracks and through beneficiary attestation. Should the voluntary attestation provision be enacted, we hope that you will work closely with CMS to ensure a robust coordination and outreach effort that extends beyond mere notification. Properly implemented, Section 401 represents an initial down payment on the reforms that are needed to ensure ACOs realize their potential to improve Original Medicare.
As a whole, the introduced legislation has potential to improve health outcomes and lower costs over time. But given the scope of the chronic disease challenge, the Committee can and should do more—particularly with respect to the highest-cost, highest-need beneficiary populations. To that end, we urge improvement in three specific areas of the bill:
- Broaden the Expansion of Independence at Home: The expansion of the Independence at Home Practice Demonstration from 10,000 to 15,000 beneficiaries, included in Section 101, would be a constructive step. But given the success of home-based primary care in the IAH Practice Demonstration and previously at the Veterans Health Administration, the Committee should not delay a broader expansion. NCHC supports the Independence at Home Act (S. 464), which converts IAH to a nationwide, voluntary program within Medicare. If it is impossible to include full conversion, the Committee should, at a minimum, expand the IAH Practice Demonstration to 50,000 beneficiaries and five years. This would allow providers in additional geographies to gain experience with this transformative care model and broaden the evidentiary base for its formal evaluation.
- Incorporate Bipartisan Steps to Support Advanced Illness Care: Advanced illness care is an important part of chronic care. During the last Congress, NCHC expressed support for S. 1549 Care Planning Act. We understand that an updated version of that legislation is nearing introduction. At a minimum, we would urge incorporation into the CHRONIC Care Act of provisions supporting advanced illness quality measure development, updating the Medicare and You handbook, and testing an Advanced Illness Care Model. Together, these policy changes can deliver meaningful improvements in outcomes and care experience for Medicare beneficiaries living with advanced stages of cancer, Alzheimer’s, dementia, renal disease, heart failure, or other conditions.
- Permit MA Plans Flexibility to Invest in Non-covered Telehealth Services: As introduced, Section 303 of the CHRONIC Care Act is an important step forward, but we believe the language should be strengthened to better align with that of the NCHC-supported CONNECT for Health Act (S. 1060). Telehealth is not a separate and distinct service, but rather a modality that enables providers to deliver already covered care in a way that improves health and lowers the cost of care without increasing utilization. An overly prescriptive approach that lists specific services that are and are not permitted may limit innovation and investment in telehealth interventions with potential to achieve significant outcome improvements and cost savings.
Finally, we reiterate NCHC’s support for providing ACOs and other alternative payment model entities increased clarity on their ability to furnish other upstream interventions that Medicare typically does not cover, such as social services, transportation, nutritional therapy, or remote patient monitoring. We regret that the Committee’s interest in this vitally important issue, discussed in the December 2015 Policy Options document, was not directly reflected in the introduced legislation. If this issue remains unaddressed in S. 870, we would encourage the Committee to quickly turn to this topic in subsequent legislative efforts this year.
If the National Coalition of Health Care can be of further assistance on these or other issues, please contact NCHC’s Policy Director, Larry McNeely, at firstname.lastname@example.org.
President and CEO
 “Independence at Home Demonstration Corrected Performance Year 2 Results,” Centers for Medicare & Medicaid Services, January 19, 2017, https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-01-19.html.
 Thomas Edes et al., “Better Access, Quality, and Cost for Clinically Complex Veterans with Home-Based Primary Care,” http://c.ymcdn.com/sites/www.aahcm.org/resource/resmgr/News_Room/Better_Access,_Quality,_and_.pdf.