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The Center for Medicare Advocacy's recent conference on adding a coordinated care benefit to the traditional Medicare program achieved a high level of agreement on the importance of changing attitudes as well as institutional factors to improve care coordination.  Of particular note is that consensus was reached on the need to get physicians directly involved and to find both financial and other means for changing the delivery of care to meet the needs of the chronically ill.

Marilyn Moon, PhD, Senior Fellow, The Urban Institute, Health Policy Center

At a Washington, DC conference convened by the Center for Medicare Advocacy, Inc. and supported by the Commonwealth Fund, a group of fifty care-providers, policy-makers, researchers, and advocates came together to discuss and formulate recommendations for a Coordinated Care Benefit to be incorporated into the traditional Medicare program. The March 2002 Conference was designed and administered by staff of the Center for Medicare Advocacy – nationally recognized experts in Medicare beneficiary coverage and appeal issues.

The Conference included leading professionals from the fields of gerontology, health law, health policy, health economics and finance, medicine, and care management for older persons and persons with disabilities. Participants met over a two-day period to discuss, frame, and refine comprehensive recommendations for a Medicare Coordinated Care Benefit.

Conferees focused on building a broader, more comprehensive definition and understanding of the function and funding of care coordination, leading to a consensus on the nature and scope of care coordination as a traditional Medicare benefit, access to the benefit, payment methodologies, and costs to beneficiaries.

As David Sandman, Senior Program Officer of the Commonwealth Fund stated:

Elderly Medicare beneficiaries with complex medical needs often cannot navigate a system in which care is fragmented, doctors don't share information, and patients have to fend for themselves.  Efforts to modernize Medicare should include a coordinated care benefit and these consensus recommendations are a sound basis for moving the policy debate forward.

The deliberations of the conferees were anchored by four background papers commissioned for the Conference. The papers discuss the issues raised by the four major disciplines represented at the Conference: the economic incentives for service provider participation, and benefit financing; the medical/clinical needs to be addressed through care coordination; the scope and nature of care management services, including medical and non-medical services; and the manner in which the benefit should be framed in the Medicare Act, as well as the necessary legal protections to be provided to beneficiaries.

The need for a Coordinated Care Benefit in the traditional Medicare program is gaining increased attention. Recent examples include the Medicare Reform Act of 2001 (S1135) which would establish a coordinated care program and a separate provision which allows the Secretary of Health and Human Services to implement disease management services. Another bill, the Medicare Modernization and Solvency Act (H.R. 803) would establish similar services. In addition, the Secretary of HHS has funded a series of case management and disease management demonstration projects. Requests for proposals for additional demonstrations have recently been circulated by the Secretary.

The Recommendations, commissioned papers, conference proceedings, and consensus statements will be compiled for publication and distribution. This work will be an important resource and springboard for further discussions about the future of the Medicare program.

Nancy Coleman, Executive Director of the American Bar Association Commission on Legal Problems of the Elderly, and Facilitator of the Conference’s Recommendation Session concurs:

Experts came together in Washington to formulate a series of recommendations that address growing concerns about our nation's need for coordinated care for those Medicare beneficiaries with multiple chronic conditions.  The recommendations provide a road map for policy makers to make valuable changes.

Recommendations for a Medicare Coordinated Care Benefit, March 22, 2002

1. The primary, over-arching goal of a Medicare Coordinated Care Benefit is to improve care.

2. Savings should not be the goal of a Medicare Coordinated Care Benefit. If savings are to be considered they must be thought of more globally than, and recognized beyond, savings only to the Medicare program.

3. The Coordinated Care Benefit must develop and promote a holistic, person-centered approach to the care and treatment of persons who are eligible for the benefit.

4. The Benefit should recognize a focus of empowering the beneficiary.

5. The Benefit will assist beneficiaries with the greatest need who are not served well by the traditional Medicare program and who would benefit from a coordinated care benefit.

6. Eligibility shall be based on having five chronic conditions (to be determined taking into consideration multiple providers, high costs, and high use of services.), OR

  • a combination of clinically complex chronic conditions which would be amenable to coordinated care, OR

  • two or more chronic conditions and functional impairments which limit the ability of the individual to manage those chronic conditions.

7. Eligibility will be periodically re-determined. Individuals who initially meet the eligibility requirements based in part on functional impairments will not be denied continued eligibility if the services are necessary to maintain their current capabilities or to prevent further deterioration of their condition.

8. The Medicare Coordinated Care Benefit is a voluntary benefit.

9. There shall be no means testing for this Benefit.

10. Election of this Benefit shall not preclude eligibility for all other Medicare benefits.

11. There must be quality control in the system, which should include a maximum beneficiary to Care Coordinator ratio.

12. The Coordinated Care Benefit consists 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.

13. Medical coordination of care and coordination of related health and social services must include monitoring, coordination among providers, and education of physicians, patients, and families.

14. The coordination of related health and social services should include physical, psycho-social, cognitive, family support needs, and risk assessment.

15. The Care Coordination Service must involve facilitating access to, and coordination of, all presently offered Medicare services and coordination of other needed and wanted services.

16. The tasks involved in coordination of such other needed and wanted services must include all necessary assessments, identification of the services, referral to the service provider, and remaining in contact with the provider of other such services.

  • These other needed and wanted services must be identified on the beneficiary’s Plan of Care.

17. Care managers should meet education, certification, and licensing requirements, and/or other Conditions of Participation as applicable.

18. A hybrid payment system should be utilized for the Coordinated Care Benefit and should encompass three reimbursable functions:

  • Initial and periodic, comprehensive, multi-disciplinary assessments, reimbursed on a fee-for-service basis,

  • Coordination of services, reimbursed on a prospective payment basis,

  • Ongoing monitoring, reimbursed on a prospective payment basis.

19. There should be a prospectively determined, "per beneficiary/per month" payment for the Coordinated Benefit, paid to the Care Coordinator, with the possibility of having some sort of complexity or acuity adjustment in the future.

20. There should be no cost sharing to the beneficiary for a Medicare Coordinated Care Benefit.

21. Reimbursement should include financial incentives to doctors to participate in the Coordinated Care Benefit.

22. Current Medicare codes should be modified to reflect the needs of caring for these patients with complex problems.

23. Alternative capitated and bundled payment methodologies for Care Coordination Services should be tested through demonstration projects or other means.

24. Payments must be adequate regardless of the payment methodology.

25. Studies shall be performed to determine what incentives will effectively encourage eligible beneficiaries to participate in coordinated care.

26. Software and technology should be provided to care coordinators to facilitate data collection and care coordination.

27. There should be a monitoring and evaluation component of the new Benefit that would include data regarding access to services.

28. Legal safeguards shall include:

  • Individual appeal rights, including the right to an expedited appeal

  • Quality review

  • Voluntary/ involuntary disenrollment rules

  • Disclosure requirements

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