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VBID Summit Explores How Congress Can Make High-Deductible Plans Work for Consumers

Mary Caffrey
Chronic Care Management
Blumenauer has co-sponsored HR. 5652, the “Access to Better Care Act,” with Representative Diane Black, R-Tennessee, which would allow patients with chronic conditions covered by HDHPs paired with health savings accounts (HSAs) access to certain services and medications on a pre-deductible basis.

During a panel discussion, Danielle Janowiski, legislative assistant to Senator John Thune, R-South Dakota, and Nick Uehlecke, a staff member for the House Ways & Means Committee, discussed efforts to work with the administration that would allow broader interpretation of IRS “safe harbor” language, which right now does not allow coverage for any “existing illness, injury, or condition,” including medication, until the deductible is met for a HDHP-HSA plan. Changing this guidance to allow for chronic care management—for example, making sure people with diabetes got insulin—would net savings by preventing hospitalizations and worse outcomes.

Fendrick said this affects both patients and physicians as practices start taking on risk under the Medicare Access and CHIP Reauthorization Act. Is it fair to penalize physicians for patients’ outcomes if HDHPs make it difficult for patients to afford basic care?

Getting patients with diabetes to get eye exams is a basic measure, for example. But if the exams are not covered until the deductible is met, “you’re discouraging my patients from doing those exact things,” Fendrick said.

Outdated Laws and Care Coordination
Speakers said some laws designed for another era must be updated to reflect today’s thinking on care coordination and VBID. For example, Tim Gronniger, senior vice president of Development and Strategy at Caravan Health, a former CMS official, said that the attempt to allow practices to charge a $42 per-patient per-month chronic care management (CCM) fee has hit snags because the Physicians’ Fee Schedule does not allow practices to waive the copayment for Medicare beneficiaries. “There’s a strong case to be made that patients shouldn’t be charged for this,” he said.

Similarly, Gronniger said the Stark Law, passed in the late 1980s to prevent physicians from referring patients to medical practices in which they owned stake, can now make care coordination a challenge. The flexibility of CMMI and accountable care organizations (ACOs) only goes so far. “People are working on it,” he said.

But evidence continues to accumulate in favor of ACOs in Medicare. Mara McDermott, vice president of federal affairs for CAPG, formerly the California Association of Physician Groups, said the percentage of premium capitation model has worked best for her members. She cited a study that appeared recently in AJMC® involving physician-led Medicare Advantage ACOs in Oregon that showed a 6% improved mortality.

Empowering the Consumer
Ann Greiner, president and CEO of the Patient-Centered Primary Care Collaborative, said robust primary care is essential for VBID to be effective, for a host of reasons.

“We’re much more mindful of a more engaged patient,” and the look and function of a practice reflects that—or should. Consumers’ expectations should go well beyond a strong physician-patient relationship.

Primary care, she said, “is the general contractor” that manages all the relationships with specialists and, at times, non-medical providers. There’s more awareness than ever of social determinants of health, of food insecurity, of behavioral health needs. Trust is essential. “If they are steering you to less expensive options, you need to trust they have your best interests at heart,” Greiner said.

And yet, she said, too few resources are put in primary care for what we expect from this level. Clinicians must be rewarded for delivering evidence-based medicine, for incorporating patient input, and for valuing shared decision-making.

She noted the brand-new findings from Choosing Wisely, which call for putting more focus on patients in the next wave of eliminating low-value care. “We want to make sure that not only costs are being looked at, but that quality is evidence-based.”

 
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