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Author: Jon Easter

In a show of bi-partisan consensus, the U.S. Senate passed the “Creating High-Quality Results and Outcomes Necessary to Improve Chronic” (CHRONIC) Care Act of 2017 by unanimous consent on September 26, 2017. The bill focuses on Medicare beneficiaries with chronic health conditions and facilitating access to programs designed to address specific needs of these populations. Treating people with one or more chronic conditions now consumes 90 cents of every dollar spent on health care, so improving outcomes for people with chronic conditions makes sense.

The fact that the Senate passed the bill a few days before the start of American Pharmacist Month struck a chord with many and we received many questions about the CHRONIC Care legislation and medication optimization opportunities.  This blog provides an overview of the Senate-passed version of the bill with a discussion of potential opportunities for pharmacists and medication optimization.

Before that discussion, however, it’s important to note that only the Senate passed the bill, so changes may and likely will come as the House takes it under consideration. (h/t Schoolhouse Rock, “I’m Just a Bill”). Specifically, the bill was referred to the U.S. House of Representatives for hearings, markups, and, if all goes well, ultimately a vote. A budget-neutral score by the non-partisan Congressional Budget Office removes a major hurdle that stalls most legislation: how to pay for it.

So, what’s in the bill and what could it mean to pharmacy? Potentially, quite a bit.

Extending the Independence at Home (IAH) Demonstration

The bill both extends the Independence at Home (IAH) demonstration for two years and increases the number of beneficiaries who could be included in the demonstration program. This successful demonstration provides shared savings incentives to care teams providing home-based care to Medicare beneficiaries with multiple chronic conditions and functional limitations.

  • Complex care services could include medication optimization, as many existing models include pharmacists as a part of the care team providing home-based services to beneficiaries.

Adding Flexibility to Medicare Advantage and Accountable Care Organizations

Many of the provisions of the Act are focused on Medicare Advantage (MA) plans and Accountable Care Organizations (ACOs).

The Act would make the Medicare Advantage Special Needs Plans (SNPs) permanent.  These plans are the only Medicare Advantage plans that can limit enrollment based on beneficiary characteristics, including: dual enrollment in Medicaid (D-SNPs); residence in a medical institutions (I-SNPs); and presence of chronic illnesses (C-SNPs).  The Act also raises the standards for care management provided by C-SNPs starting in 2020.

  • Current Centers for Medicare and Medicaid Innovation grants include medication optimization-related efforts involving duals and people with chronic illnesses.  These efforts and results will be relevant to SNPs providing services to these beneficiaries.  Matching the higher standards that would be required of C-SNPs with medication optimization outcomes should provide opportunities to demonstrate how plans can meet those standards through medication optimization strategies.

The bill would expand a current value-base insurance design (VBID) demonstration under the Center for Medicare and Medication Innovation (CMMI) to allow any MA plan interested to participate. The VBID model allows MA plans to structure benefits and include incentives that encourage use of treatments and services the plan has determined to be of higher value.

  • Many of the VBID models developed by employers involved lowering out-of-pocket costs for prescription medicines for ambulatory-sensitive conditions, including diabetes, asthma, and cardiovascular conditions. Expanding this program could provide opportunities for pharmacists to help identify treatment regimens that deliver the value sought.  Some models may include significant formulary limitations with high out-of-pocket costs for non-formulary drugs and other restrictions on access.  In those models, the ability to demonstrate the value of optimizing medication use compared against the total cost of care could prove illusive.

MA plans would be given greater flexibility to provide extra benefits to chronically ill beneficiaries.  MA plans with premiums below the benchmark for their region may use the “rebates” they receive to provide additional benefits to their enrollees.  Those benefits for chronically ill enrollees may include benefits that are not medically related, such as social supports, transportation, etc. and could be limited to enrollees based on the medical conditions.

  • MA plans could include enhanced pharmacy services as an extra benefit for chronically ill enrollees who could benefit from these services. If these services further reduce the total cost of care for the population, they could potentially “pay for themselves” by helping the plan to keep premiums under the premium benchmark and earning rebates.

For ACOs, the legislation would change how Medicare enrollees are assigned to an ACO and provide ACOs with additional flexibility to incentivize enrollee use of primary care services and preventive care.  As a part of the ACO Beneficiary Incentive Program, ACOs could provide cash incentives to enrollees (up to $20) to receive appropriate preventive and primary care services.  These incentives are funded by the ACOs, not Medicare, so will hinge on the ACO’s determination that these services reduce costs.

  • Making the case for medication optimization to ACOs could encourage ACOs to utilize these services for their chronically ill enrollees and potential provide enrollees incentives to participate. Demonstrating how these services help ACOs both meet quality benchmarks and deliver cost savings will be critical to generating interest and adoption.

Expanding Access to Telehealth Services

The bill includes several provisions dedicated to expanding access to telehealth under Medicare as Medicare limits the availability of these services to beneficiaries who receive the treatment at certain sites located in rural areas.

Most relevant to medication optimization services, the Act would allow MA plans to cover telehealth services and build these services into their bid submitted to Medicare.  Currently, the plans have to fund these services using rebates received when their bid is less than the benchmark for their region.

The legislation also allows ACOs accepting “downside risk” (or, accepting the financial risk for losses if their costs for services exceed projected cost benchmarks) to provide telehealth services to a patient’s home regardless of where the patient lives.

  • Expanding access to telehealth services could provide additional opportunities for medication optimization, including promoting applications adherence, providing remote monitoring, and facilitating self-management skill building and patient engagement.

GAO Study on Medication Synchronization

The bill would require the Government Accountability Office (GAO) to examine medication synchronization programs and report to Congress as to whether these programs improve adherence, patient outcomes, and patient satisfaction.

  • GAO studies are respected, detailed reports with potential influence beyond Congress. Assuring that the GAO has the most up-to-date, accurate information for its evaluation will be important and provides an opportunity to engage and share results. Also, a favorable report could prove influential with payors beyond Medicare.

Next Steps for The Legislation

As noted, there are hurdles to overcome before the CHRONIC Care Act or some form of it becomes law.  If and when the House passes a bill, if the House and Senate version differ, a conference comprised of House and Senate representatives of both parties meet to iron out differences and report out a single bill that both Houses have to vote on again.  A favorable vote by both the House and Senate (typically, a lock at this stage of the process) sends the bill to the President for signature.  The desire for some legislative accomplishments on health care shared among both Houses, the White House, and political parties, provides hope that a CHRONIC Care Act will become law.

Next Steps for the Pharmacy Community

In the meantime, it makes sense for the medication optimization community to both continue building the case to demonstrate value and to report results in a way that speaks to the key players.  How does medication optimization help: Both payors and providers meet quality and cost benchmarks? Create workforce efficiencies?  Lower total cost of care? Improve health outcomes?  Aligning the benefits of medication optimization with the financial risks and quality benchmarks payors and providers face is critical in the current environment, and passage of the CHRONIC Care Act will provide even more opportunities.



About the Author:

Jon Easter is the Director of the Center for Medication Optimization through Practice and Policy at the University of North Carolina Eshelman School of Pharmacy in Chapel Hill, N.C.

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