The Blog to Transform Advanced Care
Advancing Care through Innovation, Observation and Collaboration.
March 3, 2017
Cynthia G. Tudor, Acting Director, Center for Medicare
Jennifer Wuggazer Lazio, Director, Parts C & D Actuarial Group, Office of the Actuary
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Ave. SW
Washington, DC 20201
Dear Drs. Tudor and Lazio,
On behalf of the Coalition to Transform Advanced Care (C-TAC), a national non-partisan, not-for-profit organization dedicated to ensuring people with advanced illnesses receive comprehensive, high-quality, person- and family-centered care, we appreciate the opportunity to comment on the Advance Notice of Methodological Changes for Calendar Year (CY) 2018 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2018 Call Letter with respect to those policies that would affect people living with advanced illness.
Specific Comment Areas
Advanced Illness Measure Exclusion
We applaud CMS for recognizing a need to identify the advanced illness population as a new and unique area of care with different measure needs. The advanced illness population represents a significant proportion of Medicare’s highest-need population. We agree with excluding this population from selected measures for services that may no longer be appropriate. Such services include preventative or maintenance interventions, such as cancer screening, tight management of blood glucose or intense control of hypertension, which are of little benefit to those in the last months of life and can result in processes and side effects that are an undue burden to patients and families.
In regard to specific measures to exclude, we would suggest the following Star Rating measures:
- Adult BMI Assessment
- Breast Cancer screening
- Intensive control of High Blood Pressure
- Comprehensive Diabetes Care
- Cervical Cancer screening
- Colorectal Cancer screening
- Intensive osteoporosis treatment following fracture
These measures are counterproductive as a person with advanced illness has a prognosis shorter than any benefits to be accrued through these services. Further, the inconvenience and personal cost for monitoring and managing conditions like moderate hypertension, moderate hyperglycemia or regular cancer screenings may result in more aggressive and often undesired care that addresses the disease but not the person (or their family). Excluding people with advanced illness from these measurements would not prohibit their providers from continuing to offer any of these services as appropriate on a per patient basis. It would just not require them to do so.
While the Call Letter addresses exclusion of measures, we strongly suggest the concurrent need for identification of additional measures specifically designed for the advanced illness population. Any new advanced illness measures need to identify and acknowledge patient preferences to ensure integration of their health and health care goals, preferences, and values including, where appropriate, transition to hospice. C-TAC would be happy to work with CMS to provide input on the development or evaluation of such measures.
Increasing the Weighting of Care Coordination
We support the CMS proposal to increase the weighting of this element in the 2019 Star Ratings. We know that care for those with advanced illness is typically not coordinated. This leads to duplicative, unnecessary visits and procedures, and to communication problems that lead to confusion and detract from the person and family’s quality of life. For this reason, care coordination is one of the key components of C-TAC’s Advanced Care Model, a new delivery and payment model recently submitted to PTAC (https://aspe.hhs.gov/sites/default/files/pdf/253406/ACM.pdf). Increasing the weighting of care coordination will provide further incentive to MAOs to improve performance in this important area.
Promoting CMMI Model Testing Among MAO Participants
We support testing to customize supplemental benefits for MA members as this will allow for more person-centered care, where the patient, family, and medical team agree on the right plan and services for that specific patient. MAOs that provide such customization are moving more closely to true person-centered care and should be encouraged in that direction. Therefore, we also support changing the Star Ratings in a manner that does not penalize organizations for testing such models. To the contrary, such organizations and testing should be encouraged by removing systems barriers inhibiting them.
We support the use of telehealth and/or other remote access technology as a valid method for patients and families to be in close contact with their medical providers, especially for a population that is particularly susceptible to the inconveniences of multiple visits to healthcare providers in the absence of this option. Therefore, we support allowing such remote interactions to count as eligible encounter in various Part C quality measures.
Thank you for the opportunity to comment on these issues. We are excited about how these changes could improve and incentivize better care for Medicare Advantage beneficiaries with advanced illness. If you have any questions, please contact Marian Grant, Director of Policy and Professional Engagement at C-TAC, at 443-742-8872 or firstname.lastname@example.org.
Marian Grant, DNP, CRNP, ACHPN, FPCN
Director of Policy and Professional Engagement
1299 Pennsylvania Ave, Suite 1175
Washington, DC 20004