New generation of seniors pushes Congress to review chronic care

Congress is considering chronic care legislation, but don’t expect final action on any proposals until next year when a new Congress and a new president take office, Capitol Hill watchers agree.

“I wouldn’t expect anything to pass legislatively in 2016 but I do think it’s important for setting up the post-election framework for what might happen in 2017,” says Josh Seidman, PhD, senior vice president with Avalere Health.

A new chronic care management (CCM) CPT code, 99490, took effect last year, allowing physicians to be reimbursed for these services. While this meant being paid for work previously uncompensated, the new code has been met with skepticism from some doctors because of inadequate copays and not knowing the number of patients needed to participate to fully recoup costs.

A 2015 report estimated that 131 Medicare patients would need to enroll for CCM services “for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services.”

Medicare spent more than $140 billion for patients with six or more chronic conditions in 2010, according to the Centers for Medicare & Medicaid Services’ (CMS) 2012 Chronic Conditions Chartbook, the latest to estimate such spending. That compared with spending $20 billion on those with zero to one chronic condition. Data released for 2014 by CMS show that 65% of Medicare fee-for-service recipients have two or more chronic conditions.

Bipartisan agreement seems to exist that chronic care issues need to be addressed, although one sticking point will be how to craft a chronic care bill that will either reduce, or at least not increase, Medicare expenditures, healthcare experts say. 

“There’s no doubt that about two-thirds of all Medicare expenditures are related to chronic care conditions and there’s a recognition that providing more incentive to manage those chronic conditions upfront, before they result in more acute needs, will reduce the need for acute services over the long term,” Seidman explains.

Late in 2015, the Senate Committee on Finance issued recommendations from a bipartisan chronic care working group it had formed. Among the recommendations: increasing the use of telehealth services to manage chronic care, and better coordinating treatment across multiple providers. 

There’s also ongoing discussion about the need for a code in addition to 99490 that designates a physician specifically for reimbursement for the time involved in coordinating services for chronic care patients. Code 99490 reimburses only one practitioner per month per practice, even if multiple professionals provide CCM for a  patient.

Any bill that emerges from the Senate is likely to include at least some of the working group’s suggestions. On the House side, the Better Care, Lower Cost Act was re-introduced in March after failing to pass in a previous session.

The finance committee’s ranking Democrat, Sen. Ron Wyden (D-Ore), said in a statement to Medical Economics that, “The future of Medicare must focus on older Americans managing multiple chronic illnesses. The Finance Committee is working hard on a bipartisan basis to produce solutions to these challenges and reinforce the Medicare guarantee for a new generation of seniors entering the program.” 

John Frank is a journalist with 38 years of experience, and a Medical Economics contributing author.