By John Reichard, CQ HealthBeat Editor
June 13, 2013 -- Medicare's expanding effort to bring team-based care to seniors and the disabled is flawed because it prevents doctors from reaching out to treat the sickest, most costly patients and is limited to certain parts of the country, the senator next in line to chair the Senate Finance Committee said at a Washington, D.C., conference last week.
Democratic Sen. Ron Wyden of Oregon called for technical changes to the rules governing team-based care. But more broadly, he said Congress needs to pass legislation to reorganize Medicare to better prevent avoidable hospitalizations of patients with chronic diseases and to keep them from developing additional chronic conditions.
Wyden spoke at a conference of executives who run "accountable care organizations," or ACOs. About 252 of these organizations have been formed by doctors and hospitals under the health care overhaul law (PL 111-148, PL 111-152) as a way to improve the quality and efficiency of treatment in the traditional Medicare program.
About 36.3 million of the 50.7 million people in Medicare—72 percent—are in its traditional fee-for-service program, which experts say is wasteful because no single provider quarterbacks care to avoid duplicative tests, prevent needlessly expensive treatment, or make sure patients get with good preventive care.
Wyden's comments were noteworthy not only because of his fresh take on how to fix Medicare. He also is due to take over the Finance Committee gavel from Chairman Max Baucus after the Montana Democrat retires in late 2014. That assumes Democrats retain control of the Senate, which is no sure thing.
Wyden emphasized that he wants to change the Medicare debate. And the recent Medicare Trustees' report saying the hospital trust fund won't become insolvent until 2026 should fool no one, he added.
"Washington has been stuck for ages in tired, circular Medicare debates about increasing premiums on the wealthy and raising the age of eligibility," he said in prepared remarks. "Those are important issues. They do not reform the health care delivery system for the sickest seniors."
He said Medicare "faces unsustainably high costs because the program has never been about what most drives costs—chronic disease. Seniors entering the Medicare program today are sicker than when their parents enrolled, with more cancer, more heart disease, and more diabetes."
Now, about 70 percent of Medicare patients have two or more chronic conditions and account for more than 90 percent of Medicare spending, or about $500 billion a year, he said. "Yet when chronic care even gets a rare mention with policy makers in Washington, it is usually dismissed with a 'we've got to improve care coordination" [comment] and everybody nods and moves on."
ACOs Need Revamping
Rules governing ACOs should be revised, he urged. One is the "attribution" rule which says an ACO must serve anyone coming in the door. The problem with the rule in its current form, he said, is that it "limits ACOs that want to specialize in chronic care from reaching out to the sickest seniors."
Another problem is that ACOs don't serve some of the parts of the country where seniors are sickest and team-based care is most needed. "For example, the evidence shows ACOs are not being set up in Alabama, where there are a lot of seniors in very poor health. But there are plenty of ACOs in Massachusetts, where the seniors have the good fortune of being some of the healthiest in the country."
Wyden added that even seniors in ACOs "may not be lucky enough to have an individual care plan, which is the centerpiece of top quality, coordinated chronic care." And ACOs should be changed to give seniors financial incentives to be as healthy as possible, he said.
Wyden said the type of care he wants is being practiced. He cited the case of Ken Coburn, a physician with Health Quality Partners in Doylestown, PA. Coburn has sought out some of the sickest patients and through careful coordination of their care has been able to cut hospitalizations by 39 percent, costs by 28 percent, and mortality by about 25 percent.
He added that Dartmouth researcher Jack Wennberg has examined the work of top-performing health systems that treat the patients with the most intense needs in high and low-cost states.
Wyden said Wennberg found that chronically ill patients can be treated at lower costs all around the country. "In fact, the evidence shows high-performing systems spent 13 to 24 percent less than the state averages for patients with the same needs," Wyden said. "Those are huge savings."
Wyden said that in the coming months he plans to work with Democrats and Republicans to turn his ideas about improving ACOs into legislation. In addition, "Medicare should be reconfigured to target areas with the highest incidence of chronic illness, and reward practitioners in those areas who improve care and hold down costs."
Chronic care "got missed" in the health care law (PL 111-148, PL 111-152), Wyden said. It establishes a "welcome to Medicare" physical that can identify chronic conditions, but has limited tools to manage them, he said.
Wyden acknowledged in talking to reporters after his remarks that ACOs now reach only a relatively small percentage of the people in traditional Medicare, however. Only 4 million of the 36 million people in traditional Medicare are part of an ACO.
"When we get to legislation, we are going to try to create incentives not just for ACOs, but for physician practices" to coordinate care, he said.