November 3, 2014
Dear Administrator Tavenner:
The Health System Transformation Task Force is pleased to provide input on the Health Plan Innovations Initiative Request for Information (RFI).
As we described in previous communications, the Health System Transformation Task Force (Task Force) is an emerging group of private sector stakeholders that is coming together to accelerate the pace of delivery system transformation. Representing a diverse set of organizations from various segments of the industry – currently including providers, health plans, employers, consumers and academic institutions – we share a common commitment to transform our respective business and clinical models to deliver the triple aim of better health, better care and reduced costs. We hope to provide a critical mass of policy, operational and technical support from the private sector that, when combined with the work being done by CMS and other public and private stakeholders, can increase the momentum of delivery system transformation.
The Task Force’s shared principles reflect our commitment to a specific timeline for the migration from fee-for-service toward payment models that promote patient-centered care and improved population health. Our outputs will not reflect the simple self- interest of any one organization or market segment, but rather agreement on common private and public approaches that will best facilitate transformation.
We appreciate the opportunity to respond to the RFI, and focus our comments on four models for health plan innovations focused on reducing costs among high cost patients (Questions 26-27 of Section III of the RFI). As you know, care for high cost patients (the 5% of fee-for-service beneficiaries who account for 43% of Medicare spending and 20% of beneficiaries who account for over 80% of Medicare spending) lacks coordination. The highest cost beneficiaries are in and out of facilities, seeing sometimes dozens of providers and taking dozens of medications. Yet all of these services do not translate into higher quality of care. Medicare FFS offers little comprehensive medical management infrastructure, including care management for the highest cost Medicare beneficiaries, even though they are the individuals who could benefit most from it.
Given the significant impact this population has and will continue to have on our health care system, we believe now is the time to begin, in earnest, to foster real collaboration among payers and providers who touch these patients and to focus on integrated approaches that improve quality and patient outcomes and experience as well as lower costs. The following suggestions address those beneficiaries outside of current care coordination programs.
We propose 4 models as starting places for addressing this particular population. All 4 models emphasize patient risk stratification and physician practice stratification that comprehensively match the right intervention and medical home for the patient with each patient’s bio-psychosocial needs. In addition, as patient needs change over time, these models intend to perfect the hand-offs between the various high risk interventions. Perfecting hand-offs will guarantee that this complex system of care meets its goals without allowing the patient and their family to fall through the cracks.
In all four models, the proposed medical management infrastructure is premised on devoting approximately 15% of total Medicare dollars towards investing in the proposed medical management infrastructure necessary to provide improved quality care and lower the total health care spend significantly.
The first of these models is a capitated approach where highly qualified health plans would partner with high quality provider networks to provide comprehensive care management for the highest-cost beneficiaries. This plan, outlined and submitted independently by Aetna, proposes to provide the top 10 percent of highcost beneficiaries enhanced benefits not currently covered under the Medicare program, including in-home personal care, transportation, and meal services. Improving care for the highest cost Medicare beneficiaries – particularly those with multiple comorbid conditions – requires solutions that extend beyond the hospital or physician office. The clinical model within this approach would rely on embedded care managers and a comprehensive personalized care plan for each beneficiary to reflect their needs and wishes. This approach also proposes to allow participating plans to liberalize the hospice benefit to broaden eligibility and allow concurrent curative care to provide the best advanced illness care for patients. Under this approach, high-performing Medicare Advantage plans would compete to deliver care to high cost beneficiaries in a given region, in partnership with a financially and clinically-aligned high quality provider network. Participating health plans would receive capitated payments and would guarantee quality outcomes and savings to the Federal government relative to fee-for-service quality and costs for the highest-cost beneficiaries over a three-year period.
The next model involves highly qualified health plans (Medicare Advantage plans) collaborating and/or supporting employed or staff model medical groups (a continuum of opportunity based on the capabilities of the medical group and innovation of the health plan) with the design and building of a comprehensive medical management infrastructure with particular attention to embedded care management, specialized home care/ palliative care, excellence around hospitalists and SNFists, high risk clinics and the like, and development of comprehensive team care. This model is based on global capitation and excellent patient and family engagement, fostering a true collaboration between the patient and provider system. This absolute collaboration ensures successful voluntary enrollment in the pilot program with conscious enrollment rather passive participation.
The third model of care is typically employed as a collaboration between Independent Physician Associations (IPA) and highly qualified Medicare Advantage plans that supports individual practices or small primary care groups with the building of medical management infrastructure. In the instance where the IPA is unable to build the necessary medical management infrastructure themselves due to lack of sophistication, financial resources, patient density or other geographic or cultural challenges, the MA plan takes much more of the lead. Where the IPA is considerably more sophisticated, the MA Plan is in more of
a supportive role. In this model, the highly qualified health plans collaborate or support the IPA in the design and/ or building a comprehensive medical management infrastructure is as described in model two, but based on enrolling all 20-25% of high risk patients in a Medicare population and 5% of patients in a Medicaid and or commercial population into the integrated array of innovative medical homes that again match the patient and family needs with the most appropriate comprehensive team care to meet those needs. The primary care physician always stays involved in the care of these highly complex patients, but the driver of the care plan is the high-risk provider team/medical home-neighborhood that is partnering with
the patient. Patients are voluntarily enrolled as part of the delivery system in which they participate. However, through exceptional patient engagement, the system may incent successful enrollment by means of patient empowerment in their own care and buy-in from the patient’s traditional care team.
In this model, the highly qualified health plan reaches out to an exceptional provider group in a geographic region and collaboratively builds a high-risk medical management infrastructure together. The infrastructure will be oriented toward supporting a provider group that is fundamentally unable to do so themselves, while maintaining continuity of care with a patient’s trusted provider. In this instance, the voluntary enrollment of patients into this model keeps a patient’s current medical provider world intact, but guarantees access for the patient and their family to the most sophisticated and coordinated care model. The model will meet the needs of the most complex patients, reinforcing an absolute collaboration between the payer, the
"extensivists" provider system and their current medical neighborhood and providers. This structure supports trust among participants and an improving system of care that would otherwise seem impenetrable to quality and cost improvement.
In addition to sharing the above models,1 we are hopeful that as CMS turns its attention more fully to this important topic, that we can meet with the Agency to provide greater detail around these proposals. We enthusiastically support the direction CMS is taking in including this topic as a portion of the current Health Plan Innovation RFI, and we express our strong support for CMS to move forward to test approaches to improving quality and lowering costs for high-cost beneficiaries by issuing a request for proposals in the near future.
We offer these suggestions from a group that represents a cross-section of the industry. We share CMS’ commitment to facilitating health system improvement. Thank you for all that you and your team are doing to improve our healthcare system for patients, payers and providers. We share your objectives and look forward to working in an aligned way to meet the promise of delivery system transformation.
Please contact Tonya Wells at firstname.lastname@example.org or 734-343-0824 with any questions.
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