Chronic Disease Management and Building Medical Homes Without Having to Transform Primary Care Practice in the Senate HELP Committee Reform Bill

Hot on the heels of the unveiling of the health reform bill in the U.S. House of Representatives yesterday, the Senate's Health Education and Labor and Pensions (HELP) Committee passed the 'Affordable Health Choices Act.' Readers can look at the summary here, or if you’re so inclined, review the complete 615 page bill here.

If the Disease Management Care Blog is reading both bills right, the Senate's HELP bill - in contrast to what's in the House - is requiring health insurers to reimburse 'high quality care that improves health outcomes through activities that shall include... chronic disease management, medication and care compliance initiatives, including through the use of the medical home model' (bolding and italics mine).

While the DMCB is slightly confused by the language 'including through,' the specific mention of 'chronic disease management' in legislative language would appear to be good news for disease management organizations. Note that Sen. Chris Dodd (D-CT), the acting Chair of HELP, represents the home State for CIGNA and Aetna, both of which have invested heavily in population-based care and disease management programs. In addition, the ailing Senator Kennedy (D-MA) represents a State that is home to Health Dialog. Readers are free to draw their own conclusions.

In addition to this, the Senate bill importantly provides for 'grants' that will support 'health teams' that, in turn, can contractually support primary care physicians in the creation of medial homes.

The DMCB is discerning a significant pattern here. As readers may recall, the House bill has a provision that funds a 'pilot' designed to test 'Community' based not-for-profit entities that can associate with primary care providers in the creation of medical homes. It would appear the Senate bill is doing the same thing, but isn't insisting on a non-profit or State sponsored status. Both approaches recognize that not all primary care providers necessarily want to build their own medical homes, but may want to associate with entities external to their practice that enables them to do the same thing. Given the considerable expense and work of 'transforming' a medical practice into a medical home, providing this option makes sense not only to the DMCB, but also maybe to the Dr. Pectors and the rest of her colleagues that inhabit the real world.

On another note, the Senate HELP bill also trumps the U.S Preventative Health Services Task Force (USPHSTF). In addition to the disease management requirement above, the bill states insurers 'will not be allowed to impose more than minimal cost sharing for certain preventive services endorsed by the USPHSTF as clinically and cost effective...' It may surprise some readers to know what the USPHSTF does NOT endorse. If readers are interested, they can check the links to services that insurers presumably could impose significant cost sharing for:

Pap smears for healthy women over age 65 years - answer
Chest x-rays to screen for lung cancer - answer
Prostate cancer screening - answer
Routine stress tests - answer
Screening for ovarian cancer - answer
Testing for the presence of diabetes in adults - answer
Counseling to promote weight loss among the overweight - answer
Counseling to promote exercise - answer

The Senate HELP Committee's Affordable Health Choices Act: A Summary and a Recommendation for a Consumer Friendly 'Nutrition Facts Label'

Readers may have already learned that one of the two major Senate Committees that are drafting health reform legislation has finally come up with a long awaited product of the political process called a "bill." While this particular piece of legislation is still a work in progress, Senator Kennedy's Health, Education, Labor and Pensions (‘HELP’) Committee’s bill has already made some progress: it has been preliminarily ‘scored’ by the Congressional Budget Office (CBO).

CBO's analysis makes for very interesting reading. What is helpful about the CBO report is that it gives a readable summary of this ‘Affordable Health Choices Act’ (AHCA), saving the Disease Management Care Blog from having to don its oxygen apparatus and blow tanks for a dive into the original legislative language. CBO then tells us how well this will work and how much this is going to cost. It ain't pretty.

According to CBO, AHCA would either mandate or impose ‘play or pay’ health insurance coverage, provide States grants to establish Massachusetts-style ‘exchanges’ that enable insurance purchasing and subsidize that purchasing on a sliding scale from 150% to 500% of the Federal Poverty Level. The bill assumes that individuals below 150% would qualify for Medicaid.

Because AHCA doesn’t mention it, there is no mention by CBO on the impact of a ‘public insurance option’ or the expansion of Medicaid. Another possibility being considered in Congress is allowing children to be covered as dependents until age 27 years, which could also change things. In addition, administrative costs are unknown and some language in AHCA needs to be clarified. As a result, CBO’s assessment is technically incomplete - which was not only pointed out in their report, but on the Director's Blog.

So with the ‘incomplete’ caveat, CBO projects that, absent any legislation, the number of persons who are less than age 65 years with insurance will go from the current level of 217 million to 228 million over the next ten years. At the same time, the number of persons without insurance will go from the current level of 50 million to 54 million - or 19% of the U.S population.

If the HELP AHCA legislation, as currently written, passes Congress, the number of persons without insurance will decrease to 36 million - or 13% of the U.S. population. About a third of these uninsured would be undocumented aliens or Medicaid eligible individuals who haven’t been signed up. What’s more, the report predicts the number of persons with employer based insurance will decline from 162 million (if things are unchanged) to 147 million.

Cost? The total cost of the sliding scale insurance subsidies is $1.28 trillion, averaging $5000 per individual. $60 billion is needed to set up the insurance exchanges. These costs would be offset by taxes on more employers presumably paying higher wages if they’re not paying for health insurance ($257 billion) plus fewer people using Medicaid and SCHIP ($38 billion) plus ‘pay’ penalties from individuals who refuse to ‘play.’ Bottom line? A whopping $1.042 trillion over ten years.

Wait a minute, says the DMCB: 36 million uninsured? OK, 24 million if we exclude illegals. 13% of the U.S. population? $1 trillion? Fewer persons with employer-based insurance? That sounds like there will still be plenty of uninsureds in 2019, which even ardent liberals find shocking. Heart breaking tales of bankruptcy and lack of access will continue to pepper the health policy landscape and we’ll have 36 million reasons to move to a single payer system.

The DMCB doesn't think it's just about the money. Americans are generally willing to give the government more money if they believe the expense is worthwhile. This is not about the eye-popping sum of $1 trillion, this is about getting $1 trillion of value for the taxpayer.

Unless the DMCB is naively misreading the CBO report, $1 trillion in exchange for ‘only’ 36 million uninsured would not seem to pass muster. The DMCB hasn't done the math, but it suspects that the Federal outlays necessary to reach higher percentages of the uninsured are not a "linear" process. Much like the "last mile" of broadband connectivity, the cost will spiral up on a logarithmic scale. Good intentions, the DMCB would like to introduce you to fiscal reality.

And don't let the notion that the report is 'incomplete' fool you. Here's a quote:

“Although this analysis reflects the proposal’s major provisions, taking all of its provisions into account could change our assessment of the proposal’s effects on the budget and insurance coverage rates—though probably not by substantial amounts relative to the net costs already identified. Public plan and expansion of Medicaid would mean additional costs.”

Given the consternation over the cost of AHCA, the DMCB would like to borrow from the ubiquitous FDA's 'Nutriton Facts Label' that is designed to help consumers quickly navigate through the ingredients and the value of pre-packaged food. A similar label is necessary for AHCA bill, so that consumers can quickly and efficiently understand what they are getting for their hard earned money. If you think about it, the only difference is that the HELP Committee is giving us a pre-packaged health reform solution. If that's a box on the DMCB's fiscial breakfast table, it recommends that the label should look like this: