Establishing A Coordinated Care Benefit
In The Traditional Medicare Program

The Center for Medicare Advocacy is pleased that there is renewed interest in the Congress for establishing a coordinated care benefit in the traditional Medicare program.  Any health care reform, including Medicare reform, must embrace a coordinated care benefit. The absence of such a benefit has been detrimental to Medicare beneficiaries for too long.

In March of 2002, the Center for Medicare Advocacy hosted a conference, sponsored by the Commonwealth Fund, to explore the development of a coordinated care benefit for the traditional Medicare program.* The resulting recommendations, agreed upon by consensus of the conference attendees, have been updated and are set out below. The scope and content of the recommendations from the conference are relevant in every respect to today's discussion and debate.

Well-known health and Medicare economist Marilyn Moon, who participated in the conference, noted that achieving agreement about the nature and shape of the coordinated care benefit is important, as is assuring physician participation.

Guiding Principles

1. The primary, over-arching goal of a Medicare Coordinated Care Benefit is to improve care;
2. While cost-savings are important and likely an overall consequence of care coordination, they should not be viewed as the primary goal of such a benefit;
3. The Coordinated Care Benefit must be holistic in approach, considering the range of medical-social needs of Medicare beneficiaries;
4. The Medicare Coordinated Care Benefit is a voluntary benefit;
5. Election of this Benefit shall not preclude eligibility for all other Medicare benefits.

Eligibility Requirements

1. Eligibility shall be based on physician certification of:

• Having three or more chronic medical conditions (to be determined taking into consideration multiple providers, high costs, and high use of services), or
• Having a combination of clinically complex chronic conditions, including mental impairments, which would be amenable to coordinated care, or
• Having multiple chronic conditions and mental and functional impairments which limit the ability of the individual to manage his or her chronic conditions;

2. Eligibility will be re-certified annually to ensure that each individual continues to receive the services that are appropriate to his or her situation. Individuals will not be denied continued eligibility if the services are necessary to maintain their current capabilities or to slow or prevent further deterioration of their chronic conditions;
3. Access to a Medicare coordinated care benefit shall be equally available to all beneficiaries regardless of income.

Elements of Care Coordination

1. A care coordination plan must be developed for persons eligible for the benefit and must be reflected in an individualized plan of care, consisting of two areas of coordination:

• Coordination among the beneficiary's doctors about clinical/medical components of care, performed by medical personnel under the supervision of a physician;
• Coordination of related health and social services, performed by a care coordinator;

2. Care coordination must include the coordination of medical care with related health and social services, including coordination among providers, and the education of physicians, patients, and families about specific patient needs;
3. The coordination of related health and social services must include physical, psycho-social, cognitive, family support needs, and risk assessment.

Care Coordinator Qualifications

Care coordinators may come from a variety of disciplines and must meet the applicable state and federal education, certification, and licensing requirements of those disciplines as a Condition of Participation in the Medicare program.

Payment

1. An adequate, prospective or bundled payment for coordinated care services should cover all payments for at least these reimbursable functions:

• Initial and periodic, comprehensive, multi-disciplinary assessments, reimbursed on a fee-for-service basis;
• Coordination of services, with payment determined on a prospective payment basis;
• Ongoing monitoring, with payment determined on a prospective payment basis;

2. Payment should be prospectively determined, "per beneficiary/per 60 day episode of care," with adjustment for case complexity;
3. There should be no cost sharing to the beneficiary for care coordination services.

Monitoring, Enforcement, and Evaluation

1. Studies shall be performed to determine incentives to encourage eligible beneficiaries to participate in coordinated care;
2. Software and technology should be provided to care coordinators to facilitate care coordination, access to services, data collection, and payment requirements.

Beneficiary Protections

Legal safeguards shall include:

• The protection of patient confidentiality and privacy;
• The right to written notice when care coordination services are denied, reduced or terminated;
• The right to appeal a denial, reduction, or termination of care coordination services, including the right to an expedited appeal;
• The right to a review, before an appropriate agency as designated by the Medicare agency, of the quality of the care coordination services received;
• Written notice of voluntary/ involuntary disenrollment or termination of care coordination relationship rules;
• Disclosure of conflicts of interest of care coordinators with respect to referrals, disclosure of ownership and business relationships among care coordinators.

It is high time for a coordinated care benefit in traditional Medicare; a benefit based on physician involvement, that recognizes the range of post-acute care needs of beneficiaries, and that provides adequate payment for care coordination. This is particularly true for Medicare beneficiaries with multiple chronic conditions, many of whom now see several physicians and other clinicians with little or no care coordination.

For further discussion of legal issues related to care coordination, discharge planning and post-acute care transitions, please contact Alfred J. Chiplin, Jr. (achiplin @ medicareadvocacy.org) in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760.

Copyright © 2009 Center for Medicare Advocacy, Inc.