How Might the CHRONIC Care Act Affect People on Home Dialysis?

Recently the U.S. Senate passed a bill called the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 or (CHRONIC Care Act). If this bill is enacted and signed by the president, at least one of the provisions in this Act should make home dialysis patients (and possibly clinics) happy. Other provisions may or may not affect home dialysis patients directly.

Title I, Section 102 of this bill would revise Section 1881(b)(3)(B) of the Social Security Act to allow home dialysis patients to use telehealth for their monthly “clinical assessments” if they have a face-to-face visit at their home dialysis clinic at least every 3 months. If passed, this would take effect on January 1, 2019. Home patients complain about the requirement to have a clinic visit monthly. This has been hard for those working patients when their clinics don’t schedule visits during non-work hours. It’s also hard for those who live a distance from the dialysis clinic, especially if they have unreliable transportation or difficulty getting around.

Medicare excluded ESRD facilities as “originating sites” for telehealth. Only certain other providers could use telehealth under Medicare. Even allowed providers could only use it to “see” patients in rural areas. The CHRONIC Care Act would allow patients’ homes to be the originating site for telehealth. Medicare would not pay a fee to the dialysis clinic when telehealth is used for home patients and the originating site is the patient’s home.

Most of the rest of the CHRONIC bill relates to Medicare Advantage (MA) plans that private insurance companies sell. For example:

• Special Needs Plans for Duals: The CHRONIC Care Act as passed by the Senate would encourage states to contract with insurance companies selling MA plans to insure those who have both Medicare and Medicaid (called “dual eligibles”, or “duals”). Patients and others need to know that MA plans may have limited networks, which may limit where a patient get dialysis. And, if no network dialysis clinic offers home dialysis, the patient may only be covered for in-center HD.
• Special Needs Plans (SNPs) for those with severe disabling chronic conditions: The CHRONIC Care Act as passed by the Senate provides this definition: …. “one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits overall health or function, have a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination and that is listed under subsection (f)(9)(A).” These SNPs would be required to provide for their members to have initial and annual assessment by experts on an interdisciplinary team. Dialysis clinics are already mandated to do this and to assess and develop a plan of care at 4 months too. The bill would require CMS to evaluate whether the SNP is meeting goals and whether its model plan of care is meeting minimum benchmarks. Dialysis clinics already must meet certain benchmarks or their reimbursement is cut. This bill would require a General Accountability Office (GAO) study of SNPs’ valued-based insurance model. In this model health benefits, cost sharing, and supplemental benefits for those with specific conditions might vary. States to be included in this study are Oregon, Arizona, Texas, Iowa, Michigan, Indiana, Tennessee, Alabama, Pennsylvania, and Massachusetts. Dialysis patients in those states might be affected if ESRD is one of the conditions.
• MA Plans and the Chronically Ill: The CHRONIC Care Act as passed by the Senate would expand the supplemental benefits that MA plans offer, including those that aren’t strictly health-related for people with certain chronic illnesses. The goal with covering these supplemental benefits would be to improve patients’ health and functioning. Some plans may cover different services from others. This may open the door for more innovation in healthcare. Again, this bill would require the GAO to do a 5-year study of supplemental benefits, usage, cost, outcomes, etc. NOTE: Dialysis patients who are not in an MA plan when they start dialysis are currently not able to join an MA plan unless it is a chronic illnesses SNP that accepts people with ESRD. The 21st Century Cures Act of 2017 that became law in December 2016, will allow dialysis patients to join any MA plan, on January 1, 2021. The “Cures Act” prohibits CMS from cancelling contracts with poor performing MA plans (those with less than 3 stars) until plan year 2019. For people on dialysis, the question is whether all MA plans will have planned well enough to serve people on dialysis, including those on home dialysis.

The CHRONIC Care Act as passed by the Senate includes more GAO studies not related to MA plans, including:

• GAO study of longitudinal comprehensive care planning: This will study how hospice and other providers that use interdisciplinary teams to plan care are able to develop a long-term plan with a patient who has a serious or life threatening disease. It will study whether patient education on “progression of the disease, treatment options, the goals, values, and preferences of the beneficiary, and the availability of other resources and social supports may reduce the beneficiary’s health risks and promote self-management and shared decision making.” This provision could be positive for ESRD patients—if they are included.
• GAO study on medication synchronization: Study of how stand-alone Medicare Part D plans, MA drug plans, and private drug plans use synchronization programs to make sure that those filling multiple prescriptions the same day are getting comprehensive counseling and adherence is promoted; includes in elements to be studied patient satisfaction among sub-populations (disease state, socioeconomic status were stated). This could benefit ESRD patients.
• GAO study on obesity drugs and health outcomes and spending: This study will look at such things as prevalence of obesity in the non-Medicare and Medicare Advantage population, use of obesity drugs compared to other behavioral approaches, physician attitudes about prescribing these drugs, how coverage policies affect those who fail to receive clinical benefit and more.

Another provision of the Senate-passed CHRONIC Care Act would allow Medicare to share Part A and Part B drug claims data with insurance company Part D plans. The goal is to improve care coordination and outcomes and reduce adverse health outcomes, including preventable hospitalizations and readmissions. The Senate-passed bill would prevent Part D plans from using the data for such things as coverage determinations, retroactive reviews, helping people enroll in another PDP, etc. Although this data sharing has the potential to help dialysis patients avoid hospitalizations, it can have a downside IF insurance companies that sell Part D plans don’t follow the law and misuse the Part A and B data they’re given…

To offset the costs in the Senate-passed CHRONIC Care Act, these funds would be eliminated:

• Medicare Improvement Fund ($270 M). This fund allowed the Secretary “to make improvements under the original Medicare fee-for-service program under parts A and B for individuals entitled to, or enrolled for, benefits under part A or enrolled under part B including adjustments to payments for items and services furnished by providers of services and suppliers under such original Medicare fee-for-service program.” Could this fund have paid for extra dialysis treatments?
• Medicaid Improvement Fund ($5 M). This fund allowed the Secretary “to improve the management of the Medicaid program by the Centers for Medicare & Medicaid Services, including oversight of contracts and contractors and evaluation of demonstration projects. Payments made for activities under this subsection shall be in addition to payments that would otherwise be made for such activities.” Could less oversight of contracts/contractors allow them to do things that could harm participants in those demonstration projects?

Keeping in mind that this Senate-passed bill is not law yet, there are some additional questions to consider:

• What do you think about clinics and home patients using telehealth for “clinic visits” 2 months in each quarter?
• What, if any, concerns do you have about MA plans’ ability to offer coverage for the unique needs of dialysis patients, which may include treatments for other conditions?
• What do you think of the topics of the GAO studies in this Senate-passed bill?
• What concerns, if any, do you have about funding for Medicare and Medicaid that this bill would cut?