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What's next for Medicare?

Even those who closely follow the latest Medicare developments are unsure what to expect this year. CMS’ Medicare Health Support (MHS) projects, which take a more traditional DM approach, have not been successful, and a handful of companies involved have dropped out.

Vince Kuraitis, JD, MBA, principal of Better Health Technologies in Boise, ID, is one of the leading experts on CMS, and even he acknowledges he doesn’t know what its next move will be.

“The legislation had very specific mandates to CMS if the projects were successful, but there’s nothing in there that says if it’s not successful, then do something else,” says Kuraitis. “I think answers are going to be within the Medicare bureaucracy, and that’s a very difficult animal to try to understand . . . I don’t see high leadership level really a champion for continuing some kind of experimentation with Medicare in DM, and so it’s very difficult to see what’s going to happen.”

Though some have viewed the early results as disappointing, Jim Giuffre, MPH, president and chief operating officer at Healthwise in Boise, says it’s still too early to decide on MHS’ results. He suggests the industry may see better results as MHS progresses, and it can then adequately gauge the successes or failures.

Gordon Norman, MD, MBA, executive vice president and chief science officer at Alere Medical, Inc., in Reno, NV, says CMS learned from MHS Phase I in the areas of program design, risk level, and targeted cost savings, and he hopes CMS returns with a better program in MHS Phase II.

Ariel Linden, DrPH, MS, of Linden Consulting Group in Hillsboro, OR, on the other hand, is not as hopeful. Linden predicts CMS won’t forge ahead with a Phase II, but will fund projects that focus on physicians rather than DM companies, such as the medical home model. “There is little hope that CMS is going to expand [MHS] to DM vendors, given that several of them have already pulled out of the demos, and the remaining programs do not appear to be meeting targets. What I do see happening is that they will use this money to expand other Medicare demonstration projects that are provider-centric, since those are showing positive early results,” says Linden.

Warren Todd, MBA, founder and executive director of International Disease Management Alliance in Flemington, NJ, says that CMS really wants DM to succeed within the Medicare community, but how CMS will deal with mixed results is less clear, because some of the original supporters of DM within CMS are no longer there, and the degree of support from new CMS staffers is uncertain. Todd says the biggest concern he has with the MHS pilots is that the initial preliminary report did not address what seems to be working and what is not working. “In my opinion,” says Todd, “the most important outcome from the collective analysis of all the MHS pilots is what works and what does not work. We need to better understand how the original commercial DM model needs to be modified to be successful in the senior market.”

Todd speculates that some of the projects have not been successful because of lack of experience in the Medicare sector, combined with the fact that the companies involved in the pilots did not have a great deal of time to tweak their commercial programs. 

Elderly patients may need “more high touch” than younger people, perhaps including some face-to-face contact. In addition, the DM companies also may not have had adequate development time to build in more technology tools, he adds.

In addition to focusing on older Medicare patients for the CMS projects, Giuffre says Medicare should invest in programs that target younger seniors who are in the early stages of their chronic conditions. “They need to make the investment earlier if they are really going to slow down the expenditures for Medicare,” he says.

Kuraitis says Medicare is involved in dozens of demonstration projects in several areas, including the Physician Group Practice project, which places the care coordination in the physician’s practice rather than with a DM vendor. If Medicare ultimately finds another demonstration project that is not a DM project and provides a better way to care for its beneficiaries, Kuraitis hopes Medicare explores that route.

“Medicare can and ought to draw conclusions about how to care for chronic care patients across a wide range of demonstration projects, whether or not they are labeled DM. How they are going to do that is very unclear, and whether they are going to do that is very unclear,” he says.

Legislation

The DM experts that Disease Management Advisor interviewed don’t expect much federal healthcare legislation this year, given the ongoing presidential race and President George W. Bush’s final full year in office.

Healthcare is at the top of most voters’ domestic issues, says Julie Meek, DNS, chief science officer at CareGuide in Coral Springs, FL, and founder of The Haelan Group in Indianapolis. Meek predicts a lot of healthcare debate and brainstorming in 2008 but doesn’t expect healthcare legislation that brings about change until 2009 or 2010.

Linden says that any CMS legislation and demonstration projects will focus on the physician, such as the medical home model. Although not much is expected out of Washington this year, there could be DM-related legislation at the state level. Meek hopes other states follow the model of the legislation she authored in Indiana a decade ago, which was finally passed in summer 2007. The measure provides state corporate tax credits for employers with between two and 500 employees that implement wellness programs.

Meek says Indiana Governor Mitch Daniels’ support of the bill was the reason the long-delayed legislation finally made it through the legislature in 2007.

Meek adds that her legislation was actually written a decade too soon.

Most employers did not have wellness programs when the bill was first written. Now, “there is a federal grassroots effort under way, and I would love to see that kind of thinking expanded across other states and federally as well,” Meek says.

Although federal legislation is not expected this year, David B. Nash, MD, MBA, chair of the department of health policy at Jefferson Medical College of Thomas Jefferson University in Philadelphia, says that doesn’t mean the DM industry should not evolve on its own. “I don’t think we should be waiting for legislation. That’s the last resort,” says Nash.