Brookings Institution Forum

Panelists Call for Medicare Chronic Care Payment Reform

June 22, 2016 02:03 pm Michael Laff Washington, D.C. –

Chronic care patients, who are hands down the costliest in the health care system, require substantial care coordination that should be better supported by Medicare payments, said health policy experts during a recent panel discussion.

Kavita Patel, M.D., (left) a primary care physician and Brookings Institution fellow, tells Robert Moffit, (center) a senior fellow at the Heritage Foundation, and Sen. Ron Wyden, D-Ore., about the obstacles she encounters in treating patients with chronic conditions.

Sen. Ron Wyden, D-Ore., one of the panelists who participated in a June 15 Brookings Institution forum titled "Chronic Care: Getting Its Complexity and Cost Under Control,"( said revising federal policy on chronic care represents the "next major undertaking in health care." Technology and medical advances make it possible for physicians to track patients with chronic conditions, but payment rules discourage communication outside of traditional office visits.

Wyden said solutions will require getting past arguments about who was for or against the Patient Protection and Affordable Care Act (ACA).

"It is time for the health care debate to grow up," he said. "What I find bizarre is the striking lack of attention to what now dominates health care, and that is chronic illness."

Treatment for patients with one or more chronic conditions consumes a whopping 86 percent of total health care spending. Two-thirds of Medicare patients have at least one chronic condition and 14 percent have six or more, a major factor in the high cost of hospital visits and acute care.

Story Highlights
  • Panelists at a recent Brookings Institution forum called for changes to Medicare that would better support treatment for chronic care patients.
  • Treatment for patients with one or more chronic conditions consumes 86 percent of total health care spending, and two-thirds of Medicare patients have at least one chronic condition.
  • Panelist Kavita Patel, M.D., a fellow at the Brookings Institution and a primary care physician at Johns Hopkins Medicine in Baltimore, described some of the important factors other than physical health that physicians must consider in chronic care treatment.

The three most prevalent chronic conditions among Medicare fee-for-service beneficiaries are high blood pressure (which affects 58 percent of beneficiaries), high cholesterol (45 percent) and ischemic heart disease (31 percent), according to CMS.(

Seniors enrolled in Medicare Part B are eligible for a free wellness visit as outlined in the ACA. However, those with chronic conditions often have to manage and make at least some payment for subsequent care on their own.

"Coordinated care is supposed to bring down costs, but Medicare rules say that care coordination is just like any other service and it comes with a copay, so care coordination pretty much goes by the wayside," Wyden said.

He advocated eliminating the Medicare copayment after the initial wellness visit. He also said coverage should include telemedicine for beneficiaries who need this service.

Wyden said bipartisan legislation that is under consideration in both the House and the Senate would, if enacted, reform chronic care policies.

Some efforts to control costs for chronic care patients are showing promise. A CMS pilot project called Independence at Home,( which covers primary care services at home for Medicare beneficiaries with multiple chronic conditions, is saving an estimated $3,000 per patient, according to Wyden.

Other panelists at the event agreed that Medicare needs changes and said reform is important even if it does not bring any dramatic budget reductions.

"I would caution not to look for big savings," said Keith Fontenot, director for public policy at the health care law and advisory firm Hooper, Lundy and Bookman. "The point is to improve care and improve patients' lives."

Achieving that improvement with chronic care patients requires attention to more than just physical health, pointed out Kavita Patel, M.D., a fellow at the Brookings Institution and a primary care physician at Johns Hopkins Medicine in Baltimore. Fee-for-service Medicare payments do not account for much of this work.

Patel discussed a 67-year-old woman with diabetes who came to her for a wellness visit. The patient was frequently in the ER at the end of each month, and the medical staff struggled to identify the reason for this. Finally, Patel's medical assistant discovered that the patient's monthly nutrition benefits ran out before the month was over, leaving her hungry. The patient continued to take insulin but her sugar levels were dropping.

"I had to figure out how to extend her food benefits at the end of the month," Patel said.

Medication reconciliation is another crucial element of care coordination, but Medicare payment policy limits that, as well. If Patel administers the shingles vaccine in her office, for instance, the patient will get a bill from the medical facility because Medicare does not cover medication in the office. As a result, Patel must write a prescription and send the patient to the pharmacy.

"That's not a good way to coordinate care," Patel said.

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