Bill Summary for the Lincoln/Collins RE-Aligning Care Act of 2009 (S.1004)

(Reaching Elders with Assessment and Chronic Care Management & Coordination)

The Medicare program must be redesigned to provide high-quality, cost-effective, and coordinated care to the growing population of elderly individuals with multiple and complex chronic conditions.  This bill would authorize Medicare Part B coverage of geriatric assessment and chronic care management and coordination services for Medicare fee-for-service beneficiaries with multiple chronic conditions, one of which may be dementia.  

Why is this Legislation Needed?

§  Foster better healthcare for seniors.  The average Medicare beneficiary has more than 15 physician visits and sees 6 different physicians annually.  Those with 5 or more chronic conditions see an average of 14 different physicians per year.  As the number of chronic conditions increases, so does the likelihood of being prescribed multiple medications, all of which adds to the risk of medication-related problems resulting in poor health outcomes.  MedPAC acknowledges that even if individual providers deliver care efficiently, overall care may be inefficient if providers do not coordinate across settings or assist beneficiaries in managing their conditions between visits.  Beneficiaries with multiple chronic conditions, including dementia, may benefit the most from care coordination as they do not always receive necessary care and often at too high a cost. 

§  Creates savings to the Medicare program.  The cost of providing health care to Medicare beneficiaries increases as the number of chronic conditions rise.  According to the Congressional Budget Office, approximately 75% of Medicare spending pays for care for beneficiaries who have 5 or more chronic conditions.  In addition, approximately 43% of Medicare costs can be attributed to 5% of Medicare's most costly beneficiaries.  CBO acknowledges that interventions focused on coordinating care for high-cost beneficiaries with multiple chronic conditions could both improve their health and reduce Medicare spending. 

§  Provides payment to coordinate healthcare services.  As highlighted in the Institute of Medicine Report, Retooling for an Aging America: Building the Health Care Workforce, the current Medicare program does not encourage physicians to coordinate health care because they are not paid for these services.  This situation results in misaligned financial incentives that reward service volume and ultimately supports a fragmented health care system for older Americans.  Under this new benefit, Medicare would pay physicians and other eligible providers to provide comprehensive geriatric assessments and chronic care management and coordination across providers and service areas. 

What Benefits are Provided?

§  Geriatric Assessment.  A geriatric assessment is a comprehensive review of an individual’s physical and mental condition, including evaluations of cognitive and functional capacities, medication regimen and adherence, social and environmental needs, and caregiver needs and resources.  A written care plan will identify problems, therapies, and assignments for future actions.  The geriatric assessment may be performed by Medicare-approved physicians, physician assistants, nurse practitioners, clinical nurse specialists, or others as the Secretary may specify.  These professionals may provide for the furnishing of services in geriatric assessment by other qualified health care professionals. 

§  Chronic Care Management and Coordination. Individuals who have been assessed and deemed likely to benefit from chronic care management and coordination services may elect to use this benefit and choose a chronic care manager.  If an individual is unable to self-manage their care, they may designate a caregiver to choose the chronic care manager.  Chronic care managers may include Medicare-approved physicians, physician assistants, nurse practitioners, clinical nurse specialists, clinical social workers, or others as the Secretary may specify. 

Chronic care management and coordination services may include: 1) development/implementation of a care plan coordinated with health care providers and agencies including interdisciplinary care conferences; 2) medication monitoring and management; 3) beneficiary education and counseling services including self-management services when appropriate; 4) family caregiver education and inclusion in the planning process; 5) telephone and/or email consultations, including 24-hour availability; 6) use of health information technology including telehealth and remote monitoring; 7) management of transitions among healthcare professionals and settings of care; 8) home visits as appropriate, and 9) information and referrals to community resources, caregiver supports, and, when appropriate, pain management, palliative care, hospice care, end-of-life planning, and additional services the Secretary may specify. 

Who is Eligible?

Medicare beneficiaries who have two or more chronic conditions that the Secretary identifies as likely to result in high expenditures are eligible.  The Secretary may consider various methodologies when identifying these individuals, such as Hierarchical Condition Category (HCC) scores, Chronic Care Warehouse data, and presence of geriatric syndromes.  Beneficiaries who have dementia and at least one other chronic condition are also eligible. 

Who is Ineligible?

Beneficiaries cannot be any of the following: receiving hospice care under Medicare; residing in a nursing facility; medically determined to have end-stage renal disease; enrolled in a Medicare Advantage (MA) plan; or enrolled in PACE.

How Will the Results be Evaluated?

This bill calls for a study and report on the effectiveness of geriatric assessment and chronic care management and coordination services within Medicare and the impact of these services on Medicare expenditures.  This report will be commissioned by the Secretary and must be completed by 3 years after date of enactment utilizing at least 24 months worth of data for analysis. 

Why Include Those with Alzheimer’s disease (AD) and other dementias?

The RE-Aligning Care Act explicitly includes those who have AD along with other chronic conditions as one of the eligibility criteria.  This is critical because over 5 million people currently have AD with rates increasing to 7.7 million by 2030, Medicare currently spends three times more on beneficiaries with AD than on other beneficiaries, and these beneficiaries have substantial difficulty managing their complex health and long-term care needs. 

Senators Blanche Lincoln (D-AR) and Susan Collins (R-ME) have introduced the RE-Aligning Care Act (S. 1004), which would provide meaningful coverage for geriatric assessment and chronic care management and coordination services.