On May 11, the House Ways and Means Subcommittee on Health heard testimony on the Chronic Care Improvement Program (CCIP). The program was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (P.L. 108-173).
In a press release announcing the hearing, Chair Nancy Johnson (R-CT) stated, “The chronic care improvement program is a major step forward for the Medicare program and the quality of health care it provides. It represents a fundamental shift in how we think about caring for our seniors and people with disabilities. This is a key element of how the Medicare Modernization Act truly modernizes the Medicare program by improving discussion and coordination between Medicare beneficiaries and their physicians.”
Mark McClellan, Administrator of the Centers for Medicare and Medicaid Services (CMS) at the Department of Health and Human Services (HHS), explained that the traditional Medicare fee-for-service system is not structured and financed to support individuals with chronic conditions. He also noted that Medicare beneficiaries “with five or more conditions represent 20 percent of the Medicare population but 66 percent of program spending. Most of [the] Medicare expenditures for care of these beneficiaries are for multiple and often preventable hospitalizations.” Dr. McClellan said that the prevalence rates for the most common chronic conditions, diabetes and congestive heart failure (CHF), are higher for minorities than all Medicare beneficiaries. “Black and Hispanic females…have diabetes prevalence rates of 25.4 percent and 23.8 percent, respectively, compared to 12.8 percent for white females and 15.4 percent for all individuals [ages 65-74],” he stated, adding, “Given these prevalence figures, improving quality and adherence to evidence-based care has the potential to improve outcomes and reduce racial and ethnic health disparities, consistent with HHS’ Healthy People 2010 goals.”
On April 20, the CMS published a request for proposals for chronic care improvement programs focused on CHF, diabetes, and chronic obstructive pulmonary disease. Dr. McClellan said that organizations eligible to implement and operate programs under the CCIP include disease management organizations, health insurers, integrated delivery systems, and physician group practices. “Each program will offer self-care guidance and support to chronically ill beneficiaries to help them manage their health, adhere to their physicians’ plans of care, and ensure that they seek (or obtain) medical care that they need to reduce their health risks,” he stated. Dr. McClellan cited a number of examples of the type of patients that could be assisted by the CCIP, including the fictitious Mrs. Johnson, a beneficiary with CHF and depression: “She could have had severe problems with medication compliance and general wellness stemming from her depression. A nurse in an IPA [individual practice association] could reach out to her on a regular basis, provide self-care support for diet and exercise, and ensure medication compliance. The physician’s office could also bring her in for group therapy and schedule preventive check-ups with the physician. The IPA could use an electronic health record to track Mrs. Johnson’s progress and communicate with her other physicians.”
Testifying on behalf of the Urban Institute, Robert Berenson said that the CCIP “is insufficient for truly addressing chronic care needs in Medicare because it lacks a focused physician component,” adding, “The Administration emphasizes that the new program creates a ‘business platform’ that will permit innovation, but the [chronic care improvement programs] ignore the reality that beneficiaries look to their personal physicians for responsibility for their health care and not business platforms whether health plans, disease management companies, or other third party-vendors.” He also noted that the programs “have not generally been designed to address successfully the needs of medically complex patients, whose needs go well beyond learning disease self-management techniques and who have multiple professionals affecting the care and treatments of their different conditions. Nor are they designed to meet the needs of individuals with dementia, and, therefore cannot benefit from disease management’s heavy emphasis on patient self-education.”
Dr. Berenson argued that the goal of the CCIP “should be to promote a patient relationship with a primary care physician or specialist willing to take overall responsibility for care coordination,” adding, “Although disease management can assist a patient’s primary physician in caring for patients with multiple chronic conditions, its role should be viewed clearly as supplementary to the personal physician’s responsibility. Disease management currently appears to serve a useful purpose because of a quality chasm in how health care is delivered. The policy objective should be to address the causes of the chasm and not merely provide a partial stopgap.”
