[Senate Hearing 115-243]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-243

                 EXAMINING BIPARTISAN MEDICARE POLICIES
                     THAT IMPROVE CARE FOR PATIENTS
                        WITH CHRONIC CONDITIONS

=======================================================================

                                 HEARING

                               	BEFORE THE

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 16, 2017

                               __________
                               
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            Printed for the use of the Committee on Finance


                                __________
                               

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                          COMMITTEE ON FINANCE

                     ORRIN G. HATCH, Utah, Chairman

CHUCK GRASSLEY, Iowa                 RON WYDEN, Oregon
MIKE CRAPO, Idaho                    DEBBIE STABENOW, Michigan
PAT ROBERTS, Kansas                  MARIA CANTWELL, Washington
MICHAEL B. ENZI, Wyoming             BILL NELSON, Florida
JOHN CORNYN, Texas                   ROBERT MENENDEZ, New Jersey
JOHN THUNE, South Dakota             THOMAS R. CARPER, Delaware
RICHARD BURR, North Carolina         BENJAMIN L. CARDIN, Maryland
JOHNNY ISAKSON, Georgia              SHERROD BROWN, Ohio
ROB PORTMAN, Ohio                    MICHAEL F. BENNET, Colorado
PATRICK J. TOOMEY, Pennsylvania      ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada                  MARK R. WARNER, Virginia
TIM SCOTT, South Carolina            CLAIRE McCASKILL, Missouri
BILL CASSIDY, Louisiana

                     Chris Campbell, Staff Director

              Joshua Sheinkman, Democratic Staff Director

                                  (ii)
                            
                            
                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman, 
  Committee on Finance...........................................     1
Wyden, Hon. Ron, a U.S. Senator from Oregon......................     3
Warner, Hon. Mark R., a U.S. Senator from Virginia...............     7

                        CONGRESSIONAL WITNESSES

Wicker, Hon. Roger F., a U.S. Senator from Mississippi...........     4
Schatz, Hon. Brian, a U.S. Senator from Hawaii...................     6

                               WITNESSES

Hayes, Katherine, director of health policy, Bipartisan Policy 
  Center, Washington, DC.........................................    10
Schwamm, Lee, M.D., professor of neurology, Harvard Medical 
  School; executive vice chairman of neurology, chief of the 
  stroke division, and director of the Partners TeleStroke 
  Network, Massachusetts General Hospital; on behalf of the 
  American Heart Association/American Stroke Association, Dallas, 
  TX.............................................................    12
Lovelace, John G., president, Government Programs and Individual 
  Advantage; and president, UPMC for You, UPMC Insurance Services 
  Division, UPMC Health Plan, University of Pittsburgh Medical 
  Center, Pittsburgh, PA.........................................    14
Rosenthal, Stephen, senior vice president for population health 
  management, Montefiore Health System, Yonkers, NY..............    16

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Hatch, Hon. Orrin G.:
    Opening statement............................................     1
    Prepared statement...........................................    37
Hayes, Katherine:
    Testimony....................................................    10
    Prepared statement...........................................    38
Lovelace, John G.:
    Testimony....................................................    14
    Prepared statement...........................................    43
Rosenthal, Stephen:
    Testimony....................................................    16
    Prepared statement...........................................    47
Schatz, Hon. Brian:
    Testimony....................................................     6
Schwamm, Lee, M.D.:
    Testimony....................................................    12
    Prepared statement...........................................    50
Warner, Hon. Mark R.:
    Opening statement............................................     7
Wicker, Hon. Roger F.:
    Testimony....................................................     4
Wyden, Hon. Ron:
    Opening statement............................................     3
    Prepared statement...........................................    54

                             Communications

Alliance for Home Dialysis.......................................    55
American College of Physicians (ACP).............................    56
Center for Medicare Advocacy.....................................    59
College of Healthcare Information Management Executives (CHIME) 
  and Association for Executives in Healthcare Information 
  Technology (AEHIT).............................................    62
Connected Health Initiative (CHI)................................    64
Health Care Transformation Task Force............................    65
Juniper Communities..............................................    68
National Association of Specialty Pharmacy (NASP)................    69

 
                 
                 EXAMINING BIPARTISAN MEDICARE POLICIES
                      THAT IMPROVE CARE FOR PATIENTS
                        WITH CHRONIC CONDITIONS

                              ----------                              


                         TUESDAY, MAY 16, 2017

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:04 
a.m., in room SD-215, Dirksen Senate Office Building, Hon. 
Orrin G. Hatch (chairman of the committee) presiding.
    Present: Senators Grassley, Roberts, Thune, Heller, Scott, 
Cassidy, Wyden, Stabenow, Cantwell, Nelson, Carper, Cardin, 
Bennet, Warner, and McCaskill.
    Also present: Republican Staff: Chris Campbell, Staff 
Director; Brett Baker, Health Policy Advisor; Erin Dempsey, 
Health Policy Advisor; Jennifer Kuskowski, Health Policy 
Advisor; and Jay Khosla, Chief Health Counsel and Policy 
Director. Democratic Staff: Elizabeth Jurinka, Chief Health 
Advisor; Matt Kazan, Health Policy Advisor; and Beth Vrabel, 
Senior Health Counsel.

 OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM 
              UTAH, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The committee will come to order.
    I would like to welcome everyone to this morning's hearing 
on bipartisan Medicare policies to improve care for patients 
with chronic conditions.
    It was almost exactly 2 years ago today that we formed a 
bipartisan working group co-chaired by Senators Isakson and 
Warner to work on legislation to address these issues. Now, 
that working group spent many months listening to stakeholders 
in the health-care community, both in person and through more 
than 850 formally submitted comments.
    In December of 2015, the working group released a 
comprehensive policy options document. In October of last year, 
we issued a legislative discussion draft. Soon after that, CMS 
finalized four of our policy proposals in its 2017 Medicare 
Physician Fees Schedule Rule, and two provisions from our 
discussion draft were included in the 21st Century Cures Act 
which President Obama signed into law this past December.
    In other words, several of the working group's policies 
have already been enacted, and we are working to get the rest 
signed into law and fully implemented.
    Toward that end, we introduced the latest version of the 
CHRONIC Care Act, a bill that encompasses the working group's 
proposals, in April. The legislation currently has 17 
bipartisan co-sponsors and has been endorsed by numerous 
organizations in the health-care community.
    Today's hearing is the latest step in our efforts. The next 
step will come later this week, as we have noticed a markup for 
Thursday morning.
    Now, I want to thank my colleague, Senator Wyden, for his 
work on this matter. His passion for improving care for those 
with chronic conditions has been a driving force behind this 
effort. And of course, we want to thank Senators Isakson and 
Warner, who have worked tirelessly to lead our working group.
    Through their efforts, the committee has not only learned 
about the burden imposed on Medicare patients living with 
chronic conditions but also identified new policies to improve 
care coordination, increase value, and lower costs in the 
Medicare program without adding to the deficit.
    Today's hearing will provide us with an opportunity to 
examine these policies more extensively so we can better 
understand how they will help patients and enable providers to 
improve care and produce better outcomes.
    The bill includes a number of policies that would improve 
care for the chronically ill through increased use of 
telehealth by giving Medicare Advantage plans and certain 
Accountable Care Organizations enhanced flexibility to target 
telehealth services to Medicare patients with chronic 
conditions.
    Senators Schatz and Wicker have been instrumental in this 
particular effort. And I am pleased to have them here with us 
to talk about how the CHRONIC Care Act advances their policy 
goals.
    Now, I would be remiss if I did not also recognize the 
Finance Committee members who have joined Senator Schatz's and 
Senator Wicker's efforts to promote the increased use of 
telehealth services. In that regard, we appreciate the 
leadership of Senators Thune, Cardin, and Warner on these 
matters.
    While many stakeholders offered key advice on telehealth 
policy, I want to thank the fine institutions in Utah for their 
help, specifically on the, quote, ``telestroke'' policy. 
Specifically, I want to recognize Dr. Jenny Majersik and Dr. 
Nicholas Johnson at the University of Utah, as well as Dr. 
Kevin Call with Intermountain Healthcare. I appreciate their 
willingness to share their experience and expertise using 
technology to properly diagnose individuals presenting stroke 
symptoms. And I look forward to hearing more on this particular 
aspect of telehealth here today.
    Of course, our bill goes beyond telehealth, making 
improvements for beneficiaries who receive care across the 
Medicare spectrum, including fee-for-service, Accountable Care 
Organizations, and Medicare Advantage.
    We have a panel of recognized experts here before us today 
to discuss all of these issues. And I want to welcome each of 
our distinguished witnesses.
    Obviously, I am well aware that there are some contentious 
debates going on in the health-care space these days, and there 
is no shortage of political and partisan points that people 
would like to make in a venue like this.
    However, for today's hearing, I sincerely hope that we can 
maintain the bipartisan spirit that has driven our efforts on 
the CHRONIC Care Act. Toward that end, I respectfully ask that 
members of the committee focus their questions on the policy 
areas specifically addressed in the bill.
    With that, I am going to turn the time over to Senator 
Wyden for any opening remarks that he would like to make.
    [The prepared statement of Chairman Hatch appears in the 
appendix.]

             OPENING STATEMENT OF HON. RON WYDEN, 
                   A U.S. SENATOR FROM OREGON

    Senator Wyden. Thank you very much, Mr. Chairman.
    And I want to thank you, Mr. Chairman, your staff, Senator 
Warner, Senator Isakson. This is an extraordinary hearing. And 
I will touch on why, but it could not have happened if you had 
not been willing to initiate a committee-wide process.
    The Chairman. Thank you, Senator.
    Senator Wyden. So to begin, I want to thank you for all of 
the efforts to make this morning possible.
    The Chairman. Thank you.
    Senator Wyden. Colleagues, I have looked forward to today 
for many years. That is because the Finance Committee is now 
beginning to tackle the premier challenge of American health 
policy, specifically by updating the guarantee of Medicare to 
better serve seniors with chronic illness.
    When I was co-director of the Oregon Gray Panthers, 
Medicare had just two parts, A and B. If you broke your ankle 
and you had surgery in the hospital, you were covered by Part 
A. If you got a really bad case of the flu and you went to the 
doctor, you were treated by the doctor in their office, and 
that was Part B. That is not Medicare today.
    Today, Medicare is cancer. It is diabetes. It is heart 
disease. It is strokes, and it is other chronic conditions. 
Seniors who have two or more of these chronic conditions now 
account for more than 90 percent of all Medicare spending.
    And today, older people get their care in a variety of 
different ways. There is still fee-for-service, and there is 
also Medicare Advantage, Accountable Care Organizations, and a 
host of innovations being tested across the country.
    Because Medicare is a guarantee, a promise of defined 
benefits, it is past time to update this promise so as to 
deliver to patients with chronic conditions the best possible 
care in the most efficient manner.
    So as the chairman touched on, the legislation today begins 
this transformation. Older people will get more care at home, 
less in institutions. There will be expanded use of lifesaving 
technology, and that is why it is so good to see Senator Schatz 
and Senator Wicker here to talk specifics. There will be a 
stronger focus on primary care and expanded use of non-
physician providers.
    Now, in my view, still to come is ensuring that each senior 
with multiple chronic conditions has an advocate to guide them 
through what can be a teeth-gnashing experience of trying to 
navigate American health care.
    Two final points, one picking up on the debate about the 
Affordable Care Act. I would just say, colleagues, this is the 
way to do it right. Doors were opened here, not closed. There 
was bipartisan cooperation, not partisan reconciliation. The 
public was asked to shape the bill, not taken for granted.
    And finally, I want to thank our partners. Chairman Hatch 
and I had Senator Warner and Senator Isakson coordinating this 
effort. The chairman has made mention of the fact that many 
colleagues, both on and off the Finance Committee, have really 
helped to produce what our witnesses are going to call this 
morning a model for how to take on tough challenges.
    It has been an honor for me to be part of this bipartisan 
effort on and off the committee. And like you, Mr. Chairman, I 
am very pleased that our colleagues, Senator Schatz and Senator 
Wicker, are here with us today.
    The Chairman. Well, thank you, Senator.
    [The prepared statement of Senator Wyden appears in the 
appendix.]
    The Chairman. We are pleased to welcome Senators Roger 
Wicker and Brian Schatz to our hearing today.
    As I mentioned in my opening statement, these two Senators 
have done a lot of work on telemedicine and telehealth issues.
    We appreciate your support and your input today, and we 
look forward to hearing your remarks on these important issues 
and your perspectives on this important topic.
    Senator Wicker will provide his statement first and then 
will be followed by Senator Schatz.
    And, Senator Wicker, if you would, please proceed with your 
remarks, and then we will take Senator Schatz's next.

              STATEMENT OF HON. ROGER F. WICKER, 
                A U.S. SENATOR FROM MISSISSIPPI

    Senator Wicker. Thank you, Mr. Chairman, Ranking Member 
Wyden, and my distinguished colleagues on this committee. It is 
a pleasure to be here.
    Thank you for allowing me to share with you what we already 
know in my home State of Mississippi: telehealth works. I am 
glad to be here to discuss the promise of telehealth and to 
celebrate the progress your committee is making with the 
CHRONIC Care Act, which I have enthusiastically co-sponsored.
    I would like to commend the leadership of the Senate 
Finance Committee for their years of work to address the cost 
and quality of chronic care in America. Today is a testimony to 
your efforts.
    I am pleased to be here today with my friend, Senator Brian 
Schatz. He and I lead the Commerce Subcommittee on 
Communications, Technology, Innovation, and the Internet.
    In the Commerce Committee, we have worked tirelessly to 
promote innovation by removing barriers to connectivity and 
expanding access to rural broadband.
    In fact, it was during a 2015 hearing of our subcommittee 
on the potential of telemedicine when Senator Schatz and I 
decided to join forces to reform how Medicare reimburses 
telehealth. We were fortunate to form a team including Senators 
Warner, Thune, Cardin, and Cochran. And the result of our 
partnership was the CONNECT for Health Act, a widely supported 
legislative proposal for telehealth.
    CONNECT for Health, S. 1016, is a product of hard work and 
determination. It is designed to improve quality of care and 
cut costs.
    I thank the committee for including telehealth provisions 
inspired by our CONNECT bill in the bill we are discussing 
today. In so doing, you are recognizing the promise of 
telehealth.
    I became interested in this topic because my home State of 
Mississippi has led the Nation in maximizing technology to 
improve patients' health. The University of Mississippi Medical 
Center in Jackson has been a leader in telehealth for over a 
decade. The team there has managed to increase access to 
quality care and cut costs by using services like remote 
patient monitoring and tele-emergency, reaching some of our 
State's most rural, vulnerable, and costly patients.
    Mississippi is a very rural State. And in fact, we have 
some of the toughest health problems too. We have the fewest 
providers per capita and the highest rates of heart disease and 
type II diabetes. These health disparities and barriers to 
access are what drove University of Mississippi Medical Center 
to experiment and innovate with telehealth.
    One of the many Mississippi telehealth success stories is 
the Diabetes Telehealth Network, a remote patient monitoring 
program that provides rural Mississippi patients who have 
uncontrolled diabetes with routine access to a provider through 
a medical tablet.
    This partnership began following 100 chronically ill 
patients in the underserved Mississippi delta. The technology 
allowed providers to monitor and care for the patients remotely 
on a daily basis, following their vital signs and intervening 
when things did not look good.
    Throughout the course of the first year, zero of the 100 
patients were admitted to the hospital. Think about that. No 
emergency room visits for any of these previously chronically 
ill patients. This is excellent care that can improve patients' 
lives.
    In fact, telehealth can save money also. The Mississippi 
Department of Medicaid found that if this remote monitoring 
program were extended to just 20 percent of Mississippi's 
diabetic Medicaid population, the State would save $189 million 
per year.
    So Mississippi Medicaid, like Medicaid programs in 
virtually every State, is expanding access to and coverage for 
telehealth and remote patient monitoring.
    However, Medicare is behind the curve, limiting access for 
millions of seniors. Imagine the incredible impact that this 
technology could have if Medicare would allow its most 
vulnerable beneficiaries to use something like remote patient 
monitoring.
    I am confident that the success we have seen in Mississippi 
can be replicated for patients across the United States upon 
enactment of the CHRONIC Care Act and ultimately enactment of 
CONNECT for Health.
    We are still looking for co-sponsors, Mr. Chairman. And we 
will not stop until access to quality care through telehealth 
is realized for Medicare patients. The CHRONIC Care Act is a 
step in the right direction.
    We have more work to do in this space, and I look forward 
to continuing to work with each of you.
    Thank you, sir.
    The Chairman. Thank you. I think I am a co-sponsor, but if 
not, put me down, all right? [Laughter.]
    Senator Schatz, we will take you now, and then we are going 
to turn to Senator Warner, who has played a significant role in 
this.

                STATEMENT OF HON. BRIAN SCHATZ, 
                   A U.S. SENATOR FROM HAWAII

    Senator Schatz. Thank you, Chairman Hatch, Ranking Member 
Wyden, and distinguished colleagues, members of the Senate 
Finance Committee, for holding this important hearing on 
bipartisan legislation.
    I am happy to co-sponsor the CHRONIC Care Act, a bill that 
can help improve outcomes and disease management for people on 
Medicare who have chronic illnesses.
    Right now, progress in modern technology has not translated 
into progress across the health-care system. That impedes the 
health system's ability to provide high-quality care, improve 
access to care, and to lower costs. And so it is time to bring 
Medicare into the 21st century by taking full advantage of 
telehealth and remote patient monitoring.
    When we are talking about telehealth, we are talking about 
using technology to provide clinical services to patients 
remotely. Telehealth more broadly can also include non-clinical 
services, like provider training.
    One type of telehealth relies on live video or audio or 
visual technology. It is like using a secure version of Skype 
or Facetime so that a patient can connect with his or her 
health-care provider. When these visits substitute for a 
traditional, in-person visit, they can save ER expenses. They 
save travel time, and they put patients back to work more 
quickly.
    Health providers can also use store and forward technology, 
another type of telehealth, which is exactly what it sounds 
like. Providers can take an image, like an X-ray or other 
clinical picture, store it, and then send it to a specialist 
anywhere on the planet.
    There is also remote patient monitoring. If a high-risk 
patient with a chronic disease needs to have her blood pressure 
or blood sugar monitored, she can use a device at home to 
collect and send that data to a provider remotely and 
continuously. This improves the outcomes for the patients with 
chronic conditions, and it saves money too.
    The Veterans Administration, the Department of Defense, and 
the private sector are all taking advantage of telehealth and 
remote patient monitoring and improving access to care, 
improving quality of care, and saving money.
    The problem is that Medicare is not. It is limited by an 
old law. Section 1834(m) of the Social Security Act, which puts 
restrictions on the use of telehealth, says that patients must 
be located in certain originating sites in order to use 
telehealth. They cannot be seen at home and can only be located 
in certain rural areas. Only certain types of physicians and 
practitioners can use telehealth under Medicare. Physical 
therapists or occupational therapists, for example, cannot. And 
remote patient monitoring is hardly covered at all.
    And that is why Senator Wicker and I, along with Senators 
Cochran, Cardin, Thune, Warner, and 13 other members of the 
Senate, and I think almost three dozen members of the House--
and everybody is invited--have co-sponsored the CONNECT for 
Health Act over the past 2 years.
    Our bill would lift Medicare restrictions on the use of 
telehealth and improve coverage of remote patient monitoring. I 
know the chronic care working group has worked in a similar 
bipartisan fashion to build consensus and find ways to advance 
legislation.
    There are four provisions in both the CHRONIC Care Act and 
the CONNECT for Health Act that would help patients to lower 
costs. These include lifting 1834(m) restrictions that hold 
back patients who have had acute strokes or need home dialysis, 
and people enrolled in Medicare Advantage and Accountable Care 
Organizations.
    While these provisions are an important first step, we 
still have further to go. We look forward to working with this 
committee to continue to advance the important provisions in 
the CONNECT for Health Act, including improving coverage of 
remote patient monitoring, lifting 1834(m) restrictions, 
including global and bundled payments, and giving the Secretary 
of Health and Human Services more flexibility to waive these 
restrictions if certain cost and quality metrics are met.
    Thank you to Chairman Hatch, Ranking Member Wyden, Senators 
Warner and Isakson, and all of the members of the Finance 
Committee for the privilege of speaking before you today. And 
especially thank you to my partner on this legislation, Senator 
Wicker.
    The Chairman. Well, thank you both very much. We are very 
appreciative that you would come and appear before the 
committee and give us your excellent remarks.
    We will turn to Senator Warner now for whatever he would 
like to say.

           OPENING STATEMENT OF HON. MARK R. WARNER, 
                  A U.S. SENATOR FROM VIRGINIA

    Senator Warner. Well, thank you, Mr. Chairman.
    And I want to commend my colleagues and friends, and I am 
proud to be one of the original co-sponsors. And I think it is 
particularly great to see that you both wore purple ties today. 
You know, I think that color coordination gives it a little 
something extra.
    Senator McCaskill. So did the chairman.
    Senator Warner. So did the chairman. [Laughter.]
    The Chairman. Yes, I should be mentioned too, I think.
    Senator McCaskill. It is a triplet.
    Senator Warner. I know. I think this shows when there is a 
will, there is a way to get to things.
    This chronic care topic is obviously extraordinarily 
critical. And I want to particularly thank the chairman and the 
ranking member for asking Senator Isakson and I to work with 
both of you on this chronic care working group. I know Senator 
Isakson is not here this morning yet. But as in so many 
projects I have worked with him on, he has been a great 
partner, as have you, Mr. Chairman, and Senator Wyden.
    I echo as well what Senator Schatz and Senator Wicker said 
in terms of telehealth being a critical part of how we deal 
with chronic care and how we get Medicare right. The truth is, 
as our population ages and Americans survive acute illnesses to 
an extent previously unimaginable, we need to make meaningful 
reforms to our health programs so that we can move Medicare 
into the 21st century to keep our promises and ensure high-
quality care.
    Although the rate of increase in national health spending 
may be slowing, our aging population and the uncertainty around 
the Affordable Care Act mean that our public health systems 
will continue to face serious financial challenges.
    I know this area particularly has been a topic for Senator 
Wyden for some time. And he has repeatedly pointed out the fact 
that if an individual has more than six illnesses in terms of 
chronic disease, well, that is only 14 percent of the Medicare 
population, but it accounts for about half of the Medicare 
spending. And as people continue to age, those numbers are only 
going to go up.
    So that means tackling systemic reform. How we treat 
patients with chronic conditions, how we pay for quality, and 
how we measure value are key challenges in what we need to get 
right.
    This chronic care working group, which we have been part 
of--and again, working with colleagues like Senator Wicker and 
Senator Schatz, I think we produced a good product. And I thank 
the chairman and the ranking member. Hopefully, we are going to 
be able to move on this, even if we cannot agree on other areas 
in the health-care field.
    Because the truth is, our current system fails to 
adequately care for patients with chronic conditions. And 
unfortunately, while our health-care system does a great job of 
paying for individual procedures--surgery, chemotherapy, hip 
replacements, et cetera--it does not do a good job at paying 
health-care providers to coordinate care and to treat patients 
in a way that takes into account how these progressing 
conditions really do affect the lives of patients and their 
families.
    This chronic care working group received over 530 comments 
submitted by the health-care community, and subsequently our 
staffs met with 80 individual stakeholder groups. We have put 
together a series of proposals that would, I believe, modernize 
our health-care system, including changes that would expand the 
telehealth services available to home dialysis patients--I have 
a daughter with diabetes, so I know how important it is to get 
that monitoring done at home--and provide greater availability 
of telehealth services to help ensure individuals presenting 
with stroke symptoms receive the best course of treatment. So 
some of the telehealth components of your legislation improve 
the design of Medicare Advantage to provide targeted, high-
value services for individuals who need them most.
    Another provision of what we are proposing would provide 
better care planning services by directing GAO to submit a 
report to Congress to inform the development of a payment code 
for comprehensive care planning. This is an issue that I have 
been working on since my tenure in the Senate. It goes back to 
my time as Governor.
    My mom had Alzheimer's for 10 years, did not speak for 9 of 
those 10 years. Trying to get that right and trying to make 
sure that we no longer maintain the distinction of being the 
only industrial nation in the world that has not had an adult 
conversation about that part of life is something that I think 
we took a step toward getting done in this chronic care working 
group.
    Although not perfect, these initiatives move the Medicare 
system towards better coordination, better quality, better cost 
effectiveness, and take a step towards moving Medicare into the 
21st century.
    And I, again, want to thank, on behalf of Senator Isakson, 
both the chair and the ranking member for letting us work with 
you on this. And I think we have a good product.
    Thank you, Mr. Chairman.
    The Chairman. Thank you. We appreciate all the work, and we 
certainly appreciate both of you at the witness table. Thanks 
for being here.
    Today we have the opportunity to hear from four other 
witnesses who will help inform our path forward on chronic 
care. I want to welcome these four witnesses and thank them for 
their willingness to testify today.
    We will first hear from Katherine Hayes, the director of 
health policy at the Bipartisan Policy Center. Prior to joining 
BPC, Ms. Hayes was an associate research professor at George 
Washington University School of Public Health and Health 
Services. Prior to joining GW, Ms. Hayes served as vice 
president of health policy for Jennings Policy Strategies, 
Inc., practiced law at Hogan and Hartson LLP, and worked as a 
health policy adviser for two large Catholic health systems and 
Cardinal Glennon Children's Hospital.
    Ms. Hayes has also served as health policy adviser to 
members of the Senate and House of Representatives in both 
political parties, served as a program consultant to the State 
of Missouri Medicaid Agency and as health and education policy 
adviser for the State of Texas in the Office of State-Federal 
Relations.
    Ms. Hayes received a bachelor of arts degree in 
international studies from the University of North Carolina at 
Chapel Hill and a juris doctorate from the American University 
Washington College of Law.
    Following her remarks, we will hear from Dr. Lee Schwamm, 
professor of neurology at Harvard Medical School and executive 
vice chairman of neurology at the Massachusetts General 
Hospital, where he is the chief of the stroke division. He also 
serves as director of the Partners National Telestroke Network 
as well as medical director for MGH Telehealth and as a co-
chair of the Innovation Council and Partners Health Care.
    He has authored over 250 peer-reviewed articles and has 
chaired or co-chaired many of the current practice guidelines 
for stroke and telehealth-enabled care delivery.
    Dr. Schwamm graduated from the Harvard Medical School in 
1991 and completed his neurological training and fellowships in 
neurocritical care and vascular neurology at the Massachusetts 
General Hospital.
    He is testifying here today on behalf of the American Heart 
Association and the American Stroke Association.
    Third, we will hear testimony from John G. Lovelace, the 
president of UPMC for You, a managed-care organization that 
serves medical assistance and Medicare Advantage special needs 
plan recipients in 40 counties in Pennsylvania. He also serves 
as president of Government Programs and Individual Advantage 
for the UPMC Insurance Services Division as well as the chief 
program officer of Community Care, a behavioral health managed-
care organization that is part of the UPMC Insurance Services 
Division. Mr. Lovelace also serves as board chair for the 
Association of Community-
Affiliated Plans.
    Mr. Lovelace received graduate degrees in rehabilitation 
counseling from the State University of New York at Buffalo and 
in information services from the University of Pittsburgh.
    Finally, we will hear from Stephen Rosenthal. Mr. Rosenthal 
is the senior vice president of population health management 
for Montefiore's Integrated Delivery System as well as the 
president of the Care Management Company LLC. He is also an 
associate in the Department of Epidemiology and Social Medicine 
at the Albert Einstein College of Medicine.
    Previously, Mr. Rosenthal spent a number of years 
practicing as a clinical audiologist. He holds a master's 
degree in science from Brooklyn College as well as a master's 
of business administration in finance, management, and 
information systems from Pace University.
    Now, I ask you all to limit your opening statements to no 
more than 5 minutes each if you can.
    And, Ms. Hayes, will you please proceed with your opening 
remarks?

   STATEMENT OF KATHERINE HAYES, DIRECTOR OF HEALTH POLICY, 
            BIPARTISAN POLICY CENTER, WASHINGTON, DC

    Ms. Hayes. Chairman Hatch, Ranking Member Wyden, and other 
members of the committee, I am honored to be here today. I 
cannot tell you how many hours I logged sitting behind you in 
the staff seats when I worked for John Chafee from Rhode Island 
back in the day.
    Today, BPC's health project is led by former Senate 
Majority Leaders Bill Frist and Tom Daschle. Our process for 
developing policy is very similar to the process that the 
chronic care working group took as it began to put together 
this CHRONIC Care bill. We are very impressed with the way this 
has worked out and commend the members of the committee for 
this open and transparent process.
    And really, thank you very much for the opportunity to have 
been able to contribute our views to the process.
    The committee's work in drafting the legislation really 
highlights the need of caring for chronically ill individuals. 
We have long known that patients with multiple chronic 
conditions have higher Medicare costs, and for decades 
policymakers have worked to address the needs of high-cost 
Medicare patients.
    Patients with multiple chronic conditions, four or more 
chronic conditions, as you know, incur average annual Medicare 
costs that are five times higher than those with four or fewer 
chronic conditions. They have hospital readmission rates that 
are twice as high, and four times as many emergency department 
visits.
    Increasingly, research shows that non-medical social 
services and supports not covered under traditional Medicare 
fee-for-service can reduce hospitalization, emergency 
department visits, and other expensive acute-care episodes when 
supports are targeted to frail and chronically ill individuals.
    Examples of these services include non-emergency 
transportation to medical appointments and home delivery of 
low-sodium or low-sugar meals for patients with heart disease 
or with diabetes or other chronic conditions. Pilot programs 
tested in the community demonstrate that these types of 
services and supports have resulted in as high as 27-percent 
reduction in medical costs and significant reductions in 
avoidable hospitalizations.
    The Medicare Advantage program has a number of barriers in 
current statute and regulation to the provision of these 
services. And the recommendations that the committee has put 
forward go a long way toward addressing those concerns. In 
fact, many of the recommendations that the Bipartisan Policy 
Center has put forward are very similar to the work that the 
chronic care working group has put forward.
    In Medicare, there is a requirement called the uniform 
benefit requirement that requires all Medicare Advantage Plans 
to offer the same benefits to all enrollees. Research has shown 
the benefits of targeting services to certain high-cost 
beneficiaries. And with the plans that we have spoken to, they 
said they would very much like to provide a lot of these 
services, but there is not clarification in the law that they 
can do these things, such as providing home-
delivered meals. In fact, there are limitations in regulations 
that allow them to do that.
    For dual-eligibles, you have suggested aligning the 
grievance and appeals process. At the same time, you are 
allowing for coverage of services that are not primarily 
health-related. BPC has supported all of these.
    In fact, we took a look at the cost of these services. We 
looked at four services--in-home-delivered meals, non-emergency 
medical transportation, minor home modifications, and targeted 
case management services--and found that within both the 
existing Medicare Advantage program, but also in other plans, 
such as Accountable Care Organizations or patient-centered 
medical homes, the cost of these services can be as little as 
$5 a month when spread across the balance of Medicare 
beneficiaries.
    In conclusion, I would like to thank the committee for 
proposing these policy changes that are recommended in the 
CHRONIC Care Act. But equally important, again, is the 
transparent and bipartisan nature of the process.
    Through these policy changes, many frail and chronically 
ill Medicare patients could benefit from improved care 
coordination, access to care in the home and in a community-
based setting, and the availability of non-Medicare-covered 
services and supports.
    I am happy to answer any questions.
    The Chairman. Well, thank you.
    [The prepared statement of Ms. Hayes appears in the 
appendix.]
    The Chairman. Dr. Schwamm?

STATEMENT OF LEE SCHWAMM, M.D., PROFESSOR OF NEUROLOGY, HARVARD 
MEDICAL SCHOOL; EXECUTIVE VICE CHAIRMAN OF NEUROLOGY, CHIEF OF 
 THE STROKE DIVISION, AND DIRECTOR OF THE PARTNERS TELESTROKE 
   NETWORK, MASSACHUSETTS GENERAL HOSPITAL; ON BEHALF OF THE 
AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION, DALLAS, 
                               TX

    Dr. Schwamm. Chairman Hatch, Ranking Member Wyden, and 
other members of the committee, thank you for the opportunity 
to testify today on behalf of the American Heart Association 
and American Stroke Association about the CHRONIC Care Act.
    We commend you for your bipartisan work to strengthen and 
improve the health outcomes for Medicare beneficiaries living 
with chronic conditions. Your legislation, if enacted, would 
help patients receive care that meets their unique chronic 
health-care needs as well as create incentives for the 
provision of coordinated care for high-cost beneficiaries.
    The American Heart Association is pleased to offer our full 
support for this important legislation.
    In addition to being a longtime volunteer for the American 
Heart Association, I am also a member of the American Academy 
of Neurology. And we have worked very closely with the AAN to 
improve Medicare's coverage of stroke telemedicine, or 
telestroke as you heard described today. We applaud you for 
including this common-sense provision in the CHRONIC Care Act.
    As you know, stroke takes an enormous toll on families and 
on our Nation. It is the number-five killer and the leading 
cause of serious, long-term disability and dementia. As the 
baby boomers age, it is vitally important that we reduce the 
burden of this devastating disease on stroke survivors and 
their families and on Federal health-care programs. By 
improving access to telestroke care, we can ease this burden.
    In the treatment of stroke, we often say ``time is brain.'' 
That is because every minute that a stroke goes untreated, 2 
million brain cells are dying along with 14 billion connections 
that go between them. And they do not grow back.
    The clot-busting drug tPA and mechanical clot retrieval 
devices are highly effective treatments for the most common 
type of stroke and significantly reduce stroke-related 
disability, but they must be administered as quickly as 
possible after symptoms start. Patients who get tPA within 90 
minutes from the start of their stroke are three times more 
likely to recover with little or no disability, and among 
patients who get a clot retrieval device for a major stroke 
within 150 minutes, 90 percent of them will recover with little 
or no disability. This is a game-changing treatment in the 
field of stroke.
    I have seen firsthand countless examples of the miraculous 
difference these treatments can make for patients. But 
unfortunately, among Medicare patients, the national average 
tPA treatment rate is only about 2\1/2\ percent. There are 
several reasons why tPA rates have remained low, including a 
shortage of stroke experts as well as patients arriving at the 
hospital too late.
    The good news, however, is that telestroke has been proven 
to increase the percentage of stoke patients who get tPA and 
get it faster. One recent study of four urban hospitals in 
Illinois with low treatment rates found that their use of tPA 
increased two- to six-fold after telestroke was implemented.
    Rapid and accurate diagnosis of stroke is a critical first 
step to ensuring that patients receive the best in evidence-
based care. Even in urban settings, patients may still 
experience delays in diagnosis and treatment. When a patient 
presents at a hospital that does not have a stroke expert, the 
emergency department can use a telestroke network to get 
instant access to stroke expertise.
    Despite the proven benefits of telestroke, Medicare's 
coverage of it is woefully outdated. The current policy, as you 
heard before, restricts coverage for telehealth services only 
to originating sites in very rural areas. I might add, for 
example, that 80 percent of people who live in Utah and Oregon 
live outside this designation.
    The most significant step Congress could take would be to 
allow Medicare to reimburse for telestroke evaluations 
regardless of patient location, as the CHRONIC Care Act will 
do.
    In addition to improving access to evidence-based care, we 
believe the greater use of telestroke will also result in cost 
savings to Medicare and Medicaid by reducing chronic disability 
and the need for expensive, long-term care. I believe this 
change in Medicare law is long overdue, and I am heartened by 
the growing number of lawmakers and organizations that have 
endorsed telestroke.
    In addition to more than 170 bipartisan co-sponsors on 
telestroke legislation in the last Congress, organizations such 
as AARP, the American Hospital Association, and the American 
Medical Association have also expressed their firm support for 
lifting Medicare's coverage restrictions on telestroke.
    In conclusion, telestroke is supported by a wealth of 
evidence and is a common-sense, cost-effective step the 
committee can take to reduce the burden of stroke as a chronic 
disease. I am convinced that expanding the use of telestroke 
will greatly improve the quality of care that stroke patients 
receive, increase the utilization of effective acute stroke 
treatments, reduce stroke-related disability for many 
Americans, and save the health-care system money. It is simply 
the right thing to do.
    We greatly appreciate the thought and deliberations that 
went into the development of the CHRONIC Care Act and for the 
opportunity to express our strong support at today's hearing. I 
urge the Senate Finance Committee to act quickly on this 
legislation and send it to the full Senate and then the House 
for approval.
    Thank you again very much for the opportunity to testify.
    The Chairman. Thank you, sir.
    [The prepared statement of Dr. Schwamm appears in the 
appendix.]
    The Chairman. Mr. Lovelace?

 STATEMENT OF JOHN G. LOVELACE, PRESIDENT, GOVERNMENT PROGRAMS 
  AND INDIVIDUAL ADVANTAGE; AND PRESIDENT, UPMC FOR YOU, UPMC 
 INSURANCE SERVICES DIVISION, UPMC HEALTH PLAN, UNIVERSITY OF 
           PITTSBURGH MEDICAL CENTER, PITTSBURGH, PA

    Mr. Lovelace. Good morning, Chairman Hatch, Ranking Member 
Wyden, and members of the committee. Thank you very much for 
the opportunity to be here this morning and to talk to you 
about the work of UPMC and the work that is affected by the 
CHRONIC Care Act.
    I have had a remarkable opportunity over the past 20 years 
at UPMC to learn about services in Medicaid, Medicare, special 
needs plans, Children's Health Insurance, behavioral health, 
and the marketplace operations.
    I have been able to expand that information by my role as 
the board chair of ACAP, where we work closely with 59 other 
health insurance and Medicaid health plans to create 
opportunities to improve care and coverage for the most 
vulnerable citizens. We believe this bill would accelerate the 
pace of innovation and quality of services for consumers, 
certainly throughout Medicare and, therefore, into other 
coverage options.
    As part of an integrated delivery and financing system, 
UPMC health plan and the companies of the Insurance Service 
Division at UPMC work very closely with world-class hospitals 
and providers to provide Medicare beneficiaries and other plan 
members with access to affordable, innovative plan benefits. 
Our collaborative and integrated delivery system model aligns 
financial incentives between payer and provider to promote 
higher-quality outcomes at lower costs. It also gives us unique 
insight into the effectiveness of new care modalities and 
payment methodologies.
    With more than 3 million covered lives, we offer a wide 
range of commercial and government-sponsored services.
    Since their creation in 2003, special needs plans have 
faced uncertainty in the form of continuing temporary 
congressional authorization. These plans are specifically 
designed to serve the most frail, medically complex, and 
vulnerable Medicare beneficiaries by ensuring that each plan 
member receives an individualized care plan as well as access 
to better-tailored and more coordinated services than he or she 
would otherwise have in fee-for-service Medicare or the broader 
Medicare Advantage program.
    While Congress has repeatedly recognized the value of these 
plans as part of Medicare, the uncertainty of their future has 
likely constrained State investment in efforts to integrate 
Medicare and Medicaid for dually eligible beneficiaries.
    UPMC currently covers 23,000 dually eligible beneficiaries. 
We are the second-largest stand-alone four-star dual plan in 
the country, and we are positioned to begin in January with the 
coordination with Medicaid long-term services and supports 
rolling out through Pennsylvania through 2018 and 2019.
    We are very supportive of the CHRONIC Care Act's initiative 
to make SNP authorization permanent. And we are supportive of 
the conditions which are laid out under which that might 
happen.
    We have also had the opportunity to work through the 
initiation of value-based insurance designs in Medicare. 
Pennsylvania is one of seven States in which this is covered. 
This offers the opportunity, as Katherine suggested, to create 
special incentives for people with chronic disease to 
participate more actively in their health care. Our particular 
program focuses on people with diabetes, congestive heart 
failure, and depression. And it allows people to engage in 
incentive programs that are completely voluntary, to engage in 
health coaching and wellness supports to improve their care.
    It is an opportunity, I think, we hope to see expanded in 
the bill in the coming year, and we will have an opportunity to 
prove its value as we move forward into 2020.
    Another challenge to rural independence in the presence of 
chronic illness is the presence of reliable access to care. 
While we have made great strides in delivering high-quality, 
appropriate care, there are many services that are not readily 
or at least not efficiently delivered face-to-face in a 
patient's home or in a community setting. To this end, plans 
and providers are increasingly adopting telehealth technology 
to provide patients with access to a growing array of remotely 
accessible services, as you have heard already this morning.
    While speed and convenience are one factor of the success 
of telehealth, the value and promise of this technology are 
something much bigger. Also valuable is the promise to develop 
healthy, active, and busy patients, but also to reach 
individuals in rural areas, residents in nursing facilities, 
and chronically ill patients living at home and in community-
based settings where physical travel may be costly, 
complicated, and burdensome.
    UPMC has analyzed data from a number of initiatives that we 
support currently in telehealth, including telepsychiatry in 
Medicaid, telestroke, teledermatology, and so forth, as well as 
online synchronous access to primary care physicians face-to-
face on the Skype methodology.
    Our evaluations on these to date have indicated there is 
not an incremental cost to this. Rather, it replaces services 
people would otherwise get in doctors' offices, urgent care 
centers, and emergency centers.
    The CHRONIC Care Act includes provisions that expand 
coverage of telehealth within Medicare Advantage. We believe 
this represents an important step toward improving program 
flexibility to better meet the needs of beneficiaries.
    We appreciate the opportunity to be here this morning. I 
would be happy to answer any questions after we are done. And 
thank you for the opportunity to speak.
    The Chairman. Well, thank you for taking time to be with us 
and help us to understand this even better.
    [The prepared statement of Mr. Lovelace appears in the 
appendix.]
    The Chairman. We will now turn to Mr. Rosenthal, and we 
will take your testimony at this time.

   STATEMENT OF STEPHEN ROSENTHAL, SENIOR VICE PRESIDENT FOR 
    POPULATION HEALTH MANAGEMENT, MONTEFIORE HEALTH SYSTEM, 
                          YONKERS, NY

    Mr. Rosenthal. Thank you, Mr. Chairman, Ranking Member 
Wyden, and members of the committee.
    I appreciate this opportunity to discuss solutions to one 
of the most vexing problems facing the Nation's health systems: 
how to effectively and efficiently care for the growing numbers 
of Americans who suffer from chronic conditions.
    I commend the committee for its unrelenting focus on this 
topic.
    Montefiore Health System is a premier academic health 
system and university hospital for the Albert Einstein College 
of Medicine. We serve 3.1 million people living in the New York 
City region and the Hudson Valley, a combination of urban, 
rural, and suburban communities.
    Approximately 80 percent of the patients discharged from 
our hospitals are enrolled in Medicare, Medicaid, or both 
programs, or are uninsured.
    Montefiore has deep roots in treating chronic disease, 
dating back to our founding in 1884 by Jewish philanthropists 
as a care facility for patients with chronic illness. Today, we 
are one of the largest health systems in the country, and we 
have more than 400,000 patients in risk arrangements across 
Medicare, Medicaid, and commercial insurance.
    As one of the Nation's original 32 Pioneer ACOs, Montefiore 
has achieved overall savings from Medicare of over $70 million 
out of a total cost of care of $2.2 billion over 5 years. We 
are now participating in the next-generation ACO program with 
55,000 beneficiaries, and we are optimistic we can continue to 
achieve savings from Medicare and reinvest those savings in our 
delivery system.
    When we applied to become a Pioneer ACO, Montefiore was a 
four-hospital system serving primarily Bronx County, one of the 
Nation's poorest and most disproportionately disease-burdened 
counties. Today, the Montefiore ACO network includes 13 
hospitals, three Federally Qualified Health Centers, and more 
than 3,800 primary care and specialty physicians, almost 30 
percent of whom are in practice in the communities they serve.
    Yet it is our decades-long experience providing care for 
the 1.4 million residents of the Bronx, 75 percent of whom 
receive their health-care services through Medicare and 
Medicaid, that gives us the experience to successfully manage 
the care of beneficiaries who are attributed to our ACO.
    If you have any doubts about the importance of this 
concentration, consider this. In our experience, 5 percent of 
the 400,000 individuals covered by Montefiore's value-based 
contracts account for 65 percent of the total cost of care, and 
that is largely because of chronic conditions.
    I would like to just briefly discuss several provisions in 
the CHRONIC Care Act, which build upon provisions included in 
the next-generation ACO program, and offer you our support for 
them.
    In our experience, prospective attribution is one of, if 
not the most important critical component in two-sided risk 
models. While retrospective assignment of patients may be 
appropriate in one-sided risk models, in two-sided risk 
arrangements, prospective attribution allows us to quickly 
identify beneficiaries with a history of high costs and high 
utilization, as well as those with the potential for becoming 
high-cost and high utilizers.
    Prospective attribution allows an ACO to deploy resources 
within a sufficient period of time to have an impact on the 
beneficiary's care and/or remain attributed to the ACO to the 
end of the measurement period.
    Your proposal to expand the ability of ACOs to employ 
telehealth solutions that we have been discussing is an 
excellent way to provide patient access to services to best 
manage their chronic disease. To serve our urban and rural 
populations faced with challenges of getting to office 
appointments, telehealth technology can be a successful 
alternative to being there.
    In addition, this tool can provide specialty consults for 
primary care physicians in more rural locations and locally as 
an alternative for mental health services where visual contact 
can be an important part of care.
    I would also ask the committee to consider an expansion of 
the definition of telehealth to include audio only and those 
modalities that allow communication between providers, care 
managers, and patients in a seamless fashion, especially in 
low-income communities that may not have access to video 
conferencing technology.
    Finally, allowing ACOs to offer incentives to their 
patients is visionary. While there may be a cost for developing 
the infrastructure to administer the benefit, it would not only 
benefit the patient directly, but also the provider by 
improving his or her quality scores, the ACO itself by 
increasing its potential for shared savings, and the Medicare 
program by lowering the total cost of care to the system.
    Incentives could potentially encourage patients to remain 
within an ACO network without limiting their choices in any 
way.
    On behalf of the Montefiore ACO and the entire Montefiore 
health system, I thank you for your efforts to advance 
accountable care with proposals that I believe have the 
potential to improve quality and lower costs.
    I look forward to working with you to achieve our shared 
goal of a better health system for all Americans.
    Thank you. I will be happy to answer any questions.
    The Chairman. Well, thank you.
    [The prepared statement of Mr. Rosenthal appears in the 
appendix.]
    The Chairman. And thanks to all four of you. You have added 
a lot to this discussion and this understanding.
    We will turn to Senator Wyden first.
    Senator Wyden. Thank you very much, Mr. Chairman. Again, my 
thanks for your making this a bipartisan effort.
    Let me begin by trying to see if you can paint a picture of 
what it is like for somebody who is 75 years old trying to 
navigate this byzantine maze of doctors' visits and multiple 
prescriptions and test after test after test.
    It seems to me, and I am reflecting on my days when I was 
co-director of the Gray Panthers, this is a labyrinth that can 
be challenging if you are, say, in your 30s and you are fairly 
healthy. So I think it would be very helpful if the four of 
you, who are real experts in this, could really paint a picture 
for what it is like if you are a senior who has multiple 
chronic conditions: cancer, say, heart disease, you know, 
diabetes, and what happens if you are basically out there on 
your own.
    In other words, if you are in a good Medicare Advantage 
plan, you will be able obviously to have some help in an 
Accountable Care Organization. Ms. Hayes talked about a 
patient-centered health plan.
    But the reality is, for lots of seniors, they are really 
out there on their own.
    And, Dr. Schwamm, you are, of course, an authority on this. 
Paint the picture of what it is like for somebody who is 75 
years old to get up in the morning and wonder how the heck they 
are going to be able to juggle all this stuff through the day.
    Dr. Schwamm. It is a very important question and 
observation. And I will answer that in two ways. One is, when 
the patient comes into the emergency room with a stroke, so 
many times they are an older patient. Sixty-five to 70 percent 
of all the strokes we see are in Medicare beneficiaries. They 
are on multiple medications. They have not been taking all 
their medicines; they either did not have the money or they did 
not understand the prescription or something got changed. They 
did not make it to their last doctor visit. So often we see a 
failure of prevention.
    Twenty-five percent of strokes happen in people who have 
already had a stroke. So the issue is not knowledge, and the 
issue is not a desire to improve their health. The real issue 
is the challenges of navigating this incredibly complex system.
    From the perspective of what it is like to be a patient in 
this community, the average length of stay in the hospital now 
after a stroke in the United States is 4 days. So in 4 days, 
you come into the hospital, you have a new disability, and you 
cannot speak well or you cannot move your arm or you cannot 
walk, you get given a hundred pieces of paper and 55 things get 
explained to you. You are discharged from the hospital.
    And unfortunately for most of our patients, it is up to 
them to figure out how to pull a team together of advocates and 
providers and really make sure that they follow through on all 
the instructions that we provide.
    Senator Wyden. What I am struck by, and, again, I am just 
trying to reflect on the days when I ran the legal aid office 
for the elderly. We handled trying to help patients in these 
cases.
    I gather that in the example that you are talking about, 
where somebody is not part of a coordinated care plan, they are 
not part of a Medicaid plan, Medicare Advantage, or an 
Accountable Care Organization even, when you discharge them 
from the hospital, I gather in a lot of instances if you ask 
the patient whom you might even send records to, whom could you 
make a follow-up call to so that somebody who is knowledgeable 
in the health field would actually be able to pick up where the 
hospital left off, that in many instances, if a person is not 
in some kind of coordinated care program, things break down 
almost at that moment after the hospital visit. Is that right?
    Dr. Schwamm. Very much so. And it is not that providers are 
doing something wrong. Everyone is doing their best. But when 
you have just had a stroke or your mom has just had a stroke, 
you are not in the right frame of mind to absorb a lot of new 
information.
    One of the things we do at Mass General, at my hospital, is 
that we make a phone call within the first few days to every 
patient who is discharged home from the hospital to make sure 
that they are taking the right medication.
    We frequently find that they have a cabinet full of 
medicines at home, and they do not know whether to take the old 
ones or the new ones. They do not even really understand what 
happened to them.
    So I cannot agree with you more about the need for a better 
way to navigate this complex health-care system to prevent what 
we all know is coming down the road, which is another major 
medical illness or event if we do not get things sorted out 
properly.
    Senator Wyden. My colleagues all have questions, but I 
appreciate particularly your point about the role of the 
providers. That is what has been at the heart of this 
bipartisan effort. Nobody thinks providers are getting up in 
the morning and saying, ``Gee, I really want to be rotten today 
to people with chronic conditions.'' Quite the opposite. I 
think they share this frustration about the lack of whom to 
turn to, particularly if you are not part of a Medicare 
Advantage plan or one of these others.
    So you have been very helpful. I will have some questions 
for the rest of you on the second round. But I want it 
understood, particularly on that last point I made--and the 
chairman has been kind enough; we meet every Wednesday and we 
talk about it--to have it understood that for the future, for 
the long term, I want somebody to be the point person, the 
point person for coordinating care for the people who are now 
essentially out there trying to make their way through this 
byzantine system on their own. We can do better than that. We 
are better than that as a country.
    So you all have been great.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Senator Roberts?
    Senator Roberts. Well, thank you very much, Mr. Chairman.
    And, Senator Wyden, I could not agree with your comments 
more.
    Let me ask the panel this. Medication is a routine and the 
most prevalent means by which we prevent and control chronic 
disease. But we read stats time and time again that show a 
large number of individuals with these chronic illnesses do not 
take their medication as prescribed.
    Included in the CHRONIC Care legislation is a provision 
that directs the Government Accountability Office to study the 
extent to which Medicare prescription drug plans use programs 
that synchronize pharmacy dispensing so that individuals may 
receive multiple prescriptions on the same day to facilitate 
comprehensive counseling and promote medication adherence.
    As a long-time champion of medication therapy management 
and through the work I have done with Senator Carper, who has 
taken the lead in this--and I thank him for that--on 
identifying and strengthening other medication adherence 
strategies like MTM and Med Sync, I want to ensure that we are 
targeting these adherence efforts to the patients who will 
benefit from them the most.
    Do you have any recommendation, any person on the panel, 
for us to consider within this CHRONIC Care package or in 
further legislation that will help us ensure we are targeting 
the right patients to improve adherence?
    Dr. Schwamm, do you want to take a shot at that?
    Dr. Schwamm. You know, every visit that I have with a 
patient, the first part of the visit is, we go over the 
medication list to make sure that it is accurate in our health 
system. And I would say that more than half of my patients are 
on at least 1\1/2\ pages of medicines. And we go through each 
one. And half the time, they cannot even tell me what the 
medicine is for, they just recognize the name, and they tell me 
that they take one or two pills of it.
    We know that for every additional medicine a patient is 
prescribed, their adherence to the regimen goes down. So the 
more you are on, the less able you are to take them. And if 
patients use something as simple as a pill dispenser, for 
filling up the pills on Monday for the whole week, they 
increase their likelihood of adherence.
    It seems crazy to me that we do not invest more money in 
making sure that the therapies we know are proven to be 
effective when taken routinely, get taken routinely.
    So again, I would encourage the committee to try to target 
the patients who have the conditions for which we have the best 
evidence that these medications reduce the risk of re-
hospitalization, major adverse events, like stroke and heart 
disease and heart failure, and work hard to strengthen programs 
that will encourage us to build new and innovative systems for 
ensuring that medication adherence is happening.
    Senator Roberts. I appreciate that.
    Would anybody else would like to comment?
    Yes, sir.
    Mr. Rosenthal. Well, I would just add to what Dr. Schwamm 
has said. One of the things we do, because it is very difficult 
often for many physicians to reach out to large numbers of 
their patients, we use a number of PharmDs, and they go out and 
help patients--because, as we pointed out, many of them have as 
many as 8 to 10 prescriptions--with the goal of trying to 
appropriately outline a plan using these pharmacists who work 
directly with the physicians to best manage the medications the 
patients are on, because it enhances the compliance ultimately 
and avoids unnecessary medical consequences. So we have added 
that.
    Senator Roberts. Mr. Lovelace, you indicated you had a 
comment.
    Mr. Lovelace. Thank you. Yes, we similarly have used 
extenders, pharmacists and nurses particularly, to interact 
with patients and other physicians around complicated regimes. 
And the three key questions to ask people, I think, in this 
complicated process are: Do you understand why you are taking 
this? Can you afford to take it? And does it make you feel bad 
in some way? And if the answer to any of those things is 
``No,'' ``I do not understand,'' or ``Yes, it makes me feel 
bad,'' then insurance rates go way down. So the opportunity 
exists to sort of get more direct interaction with a patient 
around the experience with the drugs.
    Many people, as Dr. Schwamm has said, have eight 
medications prescribed by seven doctors. So only the patient 
knows the whole regime, not the prescribers. The pharmacist is 
an opportunity to pull it all together.
    Senator Roberts. What about over-the-counter? Seniors watch 
TV a lot, and you see all of these ads that say very positive 
things about the medication they are trying to sell or promote. 
And then they always list everything that could happen to you, 
at the bottom. But I think probably a lot of seniors go in and 
buy these products, adding to their prescriptions. The mix of 
that I am not too sure works very well.
    Would you comment on that and how we could get our arms 
around that one?
    Dr. Schwamm. Well, I am not sure I can tell you how to get 
your arms around it. But I think there is a misperception that 
things you can buy over the counter are not drugs or 
medications. And I counsel my patients frequently that they 
need to tell me everything they take on a regular basis, 
including things they buy in the health-food store or what we 
might call nontraditional medications. Because many times, 
patients may be taking things that interfere with the 
effectiveness of the treatments we are trying to get them to 
take.
    And as I mentioned before, it is the number of things you 
take every day that leads to you not taking them regularly. So 
that includes over-the-counter medicines as well. And we know 
that over time we discover that there are harmful effects for 
many of the things we had presumed to be benign or only have 
beneficial effects.
    Polypharmacy is the name that is used sometimes to describe 
this mixture of medications, and the idea of reconciling those 
medicines and looking for interactions between them is 
incredibly important.
    If you practice in an integrated health-care system, the 
software that you use to prescribe medicines will often alert 
you to dangerous interactions between medicines that you might 
not have been aware of. So I think anything we can do to 
strengthen the support at the time of prescribing and at the 
time of visits that will help providers and patients understand 
dangerous interactions between medicines is very important.
    Senator Roberts. I thank you for that.
    And my time is expired. And I just want to thank again 
Senator Carper for working with me, and I am working with him 
on this legislation. Thank you.
    The Chairman. Great.
    Senator Stabenow?
    Senator Stabenow. Well, thank you very much, Mr. Chairman.
    And I want to echo Senator Roberts's concerns about what is 
happening on medications and appreciate very much what all of 
you are doing.
    And, Mr. Chairman, I want to thank you for the hearing 
today--I am a proud co-sponsor--and, Senator Wyden, for your 
passion on this, the CHRONIC Care Act. It is a product of 2 
years of bipartisan work and engagement of hundreds of 
stakeholders.
    And I think this is just a very, very important model of 
how we should be going forward, frankly. When we did the last 
major health reform that is now under such great political 
debate, we had a hundred meetings and hearings in the Senate 
between the Finance and the HELP Committees.
    So I would hope that we are going to be focusing on 
improving quality, lowering costs, lowering premiums, creating 
more quality. And I would very much hope--and I am very sincere 
in this--that whatever product comes forward in the Senate, 
before it comes to the floor, that we have an opportunity to 
have a hearing on impact, because this is really important. 
This represents one-fifth of the gross domestic product, and it 
affects every single American.
    The other thing that I would say--because it is so 
important as we are looking at this discussion, which is very 
positive, thoughtful, and the right discussion--is that for 
seniors, people with multiple chronic conditions, people in 
nursing homes, and so on, the bill that came over from the 
House is exactly in the opposite direction: $880 billion being 
cut from Medicaid. And in Michigan, three out of five seniors 
in nursing homes and half the people with disabilities are 
covered by Medicaid.
    So I am just underscoring this, why it is so important that 
we have input, because this bill, the CHRONIC Care Act, is very 
positive. And what has come to us from the House is very, very 
negative and would undercut everything that we are talking 
about.
    I want to specifically talk about the Value-Based Insurance 
Design today. It is not something that everyone in the public 
really would be thinking of in terms of an improvement in the 
system, but I would probably have to say this is a Michigan 
export.
    In 2005, Dr. Mark Fendrick started the University of 
Michigan Center for Value-Based Insurance Design. They have 
done terrific work in evaluating innovative health-plan benefit 
designs to improve care and lower costs.
    And Senator Thune and I have worked on this, as well as 
many others. And this bill would take this from a pilot in 
seven States, as you know, to the opportunity for every State 
to use this.
    So first, Mr. Lovelace, I know you mentioned that your 
health plan is participating in the VBID model. And I wonder if 
you could talk a little bit more about that: the types of plan 
designs that you have incorporated. Have you used them in other 
commercial plans? And have you seen any results so far? And 
what would those results be?
    Mr. Lovelace. Sure, I would be happy to. We have about 
8,000 enrollees in Medicare Advantage who are eligible to 
participate in the Value-Based Insurance Design program, who 
have the combination of conditions that are targeted. And we 
have had the opportunity to have a lot of consultation with Dr. 
Fendrick and his staff around what he knows and what he has 
learned and how that informs the program. And he has really 
been very supportive of our work in this area.
    I think it would be fair to say at month number four that 
we do not really have any results yet. The plan we have 
designed basically is a series of six $25 incentives which we 
have to pay in checks as people choose to achieve certain 
goals.
    The drill basically is, the first incentive is, do you 
agree to talk to a health coach? You have agreed to participate 
in the process. The second step is, you set some goals for 
yourself. They are whatever you want them to be. They could be 
diabetic-related, they could be something else.
    The next four steps really are that you establish some 
steps along the goals and you work on the steps. You do not 
have to achieve them. You do not have to lose weight if that is 
your goal. You do not have to have an A1C under 9 if that is 
your goal. But you do have to make an effort to work on it.
    Most people who have been offered a chance have been 
enthused about it. It is a lot of time to spend on the phone 
with health coaches. And Medicare recipients on the whole like 
to talk on the phone to people. [Laughter.]
    They like some help, because they are often bewildered by 
the whole system. And anybody who has a glimmer of how to get 
through this in one piece is helpful. So it has been also an 
engaging experience.
    We are pleased by the uptake early on, and we look forward 
to evaluating this as we move along.
    We do have incentives in our commercial programs with some 
very nice results. We have incentives around health and 
wellness issues, including setting goals around things like 
weight loss and blood pressure control, that have a different 
kind of financial payoff to people, that essentially eliminate 
your deductible by engaging in healthy behaviors. And we have 
about 85-percent uptake in this actually. It is significant; 
you can save about $1,000 a year in your deductible if you 
engage in certain behaviors.
    It definitely catches people's attention; $500 did not 
actually. So we have sort of experimented to find where the 
level is that people pay attention, and it seems to be about 
$1,000.
    Senator Stabenow. Thank you so much. It turns out health 
care is complicated. Who knew?
    Mr. Lovelace. I did not know. [Laughter.]
    Senator Stabenow. All right. I am out of time.
    The Chairman. You are.
    Senator Stabenow. I do not know if anyone had a quick 
comment.
    I am out of time, so I guess I will leave it there, Mr. 
Chairman.
    The Chairman. Thank you. Thank you, Senator.
    Senator Carper, you are up.
    Senator Carper. Thanks, Mr. Chairman.
    To one and all, welcome. Thank you for trying to help us 
and help us really better assist the folks whom we represent.
    My mom died a number of years ago. She had dementia for the 
last years of her life. So did her mother, so did her 
grandmother. And she lived down in Florida near Clearwater, and 
my sister and I would take turns going down and seeing her. 
About every other month we would take turns.
    And one of the things that my mom did was, she had what 
looked like a fishing tackle box in her house that had no 
fishing tackle in it, but it had a lot of medicines. And she 
would take one before breakfast, one at breakfast, something 
after and throughout the day and into the night. And she 
reached a point in her life where she could not do it on her 
own. My dad was deceased, so we hired people to come and be 
with her part of the day and eventually 24/7, to help her.
    One of the things that we found out was, she had seven 
doctors, and they were prescribing a total of 15 different 
medicines. The doctors never talked to each other. And we were 
convinced that some of the medicines she was taking were just 
fine for her conditions, but some were probably not.
    And so one of the things that Senator Roberts and I are 
doing with the help of our staffs is to figure out what are 
better ways to do that, and I am sure there are.
    But you all have talked about this already, but just talk 
to us about best practices. I do not care who goes first, but 
just talk about practices to deal with situations like that. I 
know they are commonplace. But somebody has figured this out, 
doing a pretty good job. Just give us some idea what the best 
practices are.
    Ms. Hayes, would you go first, just briefly?
    Ms. Hayes. Sure. I think some of the best examples have 
been done through dual special needs plans, particularly 
those--there are a couple of States that have been more 
forward-thinking.
    One in particular that I am familiar with is in 
Massachusetts. And they have done just an amazing job of 
providing the sort of coaching that dual-eligibles need to make 
sure they get their drugs at the right time, to make sure that 
when they are discharged from the hospital, they have what they 
need.
    But most importantly, and to Senator Wyden's point, they 
have someone they know whom they can call at the plan. They 
have a phone number and the name of a person whom they can call 
when they need help, or their caregiver can, if, as in the case 
of your mother, she is not able to do it.
    Senator Carper. All right; thanks.
    Dr. Schwamm?
    Dr. Schwamm. This is the concept of the patient-centered 
medical home, which I view as really a kind of recreation of 
the era of Marcus Welby, you know? There was someone in the 
doctor's office who knew you, knew you well, and knew your 
circumstances, and there was a community around you that would 
tell you that you needed help if you looked like you were 
struggling.
    We live in a very different society now, but we need to 
figure out ways to coordinate the care so somebody in the end 
takes ownership for that person and really owns the health 
issues around them and makes sure that the medicines are 
reconciled, makes sure that the specialists are coordinated. 
Because, as was just said a minute ago, medical care is really 
complicated now.
    Senator Carper. Yes, thank you. I was watching the audience 
when you said ``Dr. Marcus Welby.'' And the people under 30 
were, like, you know----
    Dr. Schwamm. Did anybody know what I was talking about?
    Mr. Lovelace. Well, I do.
    Senator Carper. Those millennials were wondering, but we 
knew. [Laughter.]
    Mr. Lovelace. It is a place where there is a particular 
role, I think, for telemedicine and telemonitoring, in terms of 
reminders to people, in terms of texts, in terms of monitoring 
what is in the pillbox. There are a lot of technology solutions 
that can support the effort of physicians and caregivers. They 
certainly do not replace them, but they certainly can help 
coordinate them beyond the points that Katherine and Dr. 
Schwamm made.
    Senator Carper. All right. Thank you.
    Mr. Rosenthal. You raise an important aspect: the benefits 
of a clinically integrated system using technology and with 
some care-coordinating capabilities within that. What we do 
through the depth and breadth of our large, clinically 
integrated system can begin to incorporate the information for 
our medical records so that all the physicians know what 
everyone else is doing and the information about medications 
and the like is incorporated within that system.
    And then we take responsibility for those individuals and 
have a care-coordinating process within our operations so there 
is someone trying to be accountable for those individuals who 
have those complicated health issues.
    Senator Carper. All right. Thanks very much.
    One of the issues that I have focused on, my staff and I 
have focused a great deal on with some of our colleagues, is 
the issue of obesity. And we are not getting any slimmer. And 
there is, I think, reason to believe that we are going in the 
wrong direction.
    But so many bad things flow from being heavily overweight. 
I was in a hospital in Dover, DE not too long ago and went into 
one of the operating rooms. They had a hoist. And I said, what 
is this for? And they said this is for people who are really 
heavy. And I said, like, how heavy? And they said one person 
was 700 pounds, 800 pounds, just unbelievable stuff.
    But in terms of getting us on the right track to do a 
better job of reversing this trend, epidemic really, toward 
obesity, just give me maybe each of you one piece of advice for 
what we should be doing here at this level to help win this 
war.
    And, Mr. Rosenthal, do you want to go first?
    Mr. Rosenthal. Well, I think it actually begins at a very 
young age. I think adolescent obesity begins the whole sequence 
that brings individuals to the complicated illnesses that 
obesity can lead to. So it begins in the school, in the school 
health systems.
    We are very active in the school health systems. We have 
one of the largest networks of school-based health care, 
educating our young children today on eating habits, exercise. 
And if we can begin at those early ages, I think we can begin 
to actually stem the tide on obesity.
    Senator Carper. All right, thanks.
    Mr. Lovelace?
    Mr. Lovelace. I would certainly agree with that. And I 
think it is mostly--it is not that we do not know what to do. 
We know we should not smoke, we know we should not be 700 
pounds, we know we should not eat cheeseburgers for breakfast, 
but people do it anyway.
    So I think it is a matter of, as Mr. Rosenthal said, 
ingraining early what healthy eating and exercise are and how 
they fit into life so it is an expectation, not something you 
have to learn and force yourself to do if you are an adult.
    Senator Carper. Thank you.
    Dr. Schwamm?
    Dr. Schwamm. These are very important contributors to 
stroke risk. And stroke rates are on the rise in younger 
Americans now, shockingly and very depressingly. Avoiding a 
sedentary lifestyle and making affordable, healthy food choices 
available routinely is critical.
    A study just came out last month showing that one diet soda 
a day triples your risk of stroke and dementia. So, you know, 
``we are what we eat,'' and we really need to be focused on 
healthy food.
    Senator Carper. Thank you.
    Katherine?
    Ms. Hayes. Yes. I think education on what to eat and the 
importance of physical activity are absolutely important. But I 
think there are a lot of confusing messages out there in 
marketing.
    My mother has heart disease and diabetes and has been 
struggling so long to keep her sugar levels low. And because 
she is not able to go upstairs and use the kitchen in our 
home--she lives with us--she was buying prepackaged meals that 
were convenient. And there is so much salt in them that she 
ended up in the hospital last week because she had too much 
sodium and started having heart problems again.
    So I would agree: making healthier foods more available and 
education.
    The Chairman. Time is up, Senator.
    Senator Thune?
    Senator Thune. Thank you, Mr. Chairman.
    I want to thank you and Senator Wyden for holding this 
important hearing. I am pleased with the progress that we have 
made so far with the bipartisan CHRONIC Care Act, and I look 
forward to continuing to work with you and the members of this 
committee on ways to further promote care coordination so that 
we can improve outcomes for Medicare beneficiaries.
    And I also want to again recognize Senators Wicker and 
Schatz, who were here earlier, and the rest of the CONNECT for 
Health working group for teaming up to increase access to 
telehealth technologies. The inclusion of a number of CONNECT 
for Health Act provisions in the CHRONIC Care Act is a step 
toward improving beneficiary access to timely and effective 
health care.
    Dr. Schwamm, thank you for being here today. Earlier this 
year, I introduced the Furthering Access to Stroke 
Telemedicine, or FAST, Act which seeks to break down existing 
barriers related to the use of telestroke technology.
    I should say, though parts of South Dakota fall into a 
health professional shortage area and may meet the geographic 
requirements that exist under the current law, you mentioned in 
your testimony that even some urban and suburban regions do not 
have access to stroke neurologists to make timely diagnoses.
    So could you talk about how geographic and originating-site 
restrictions on telehealth technology have limited access to 
effective, but time-sensitive treatments for stroke victims, 
both in rural and urban areas?
    Dr. Schwamm. Yes. I think it would surprise people on the 
committee to know that 90 percent of the strokes in the United 
States every year are occurring outside of that coverage area. 
So the area for which Medicare has designated coverage is 
actually a relatively small geographic swath of the United 
States, and it is not very densely populated. So the places 
that need this treatment are not far from where you and I live.
    When I first started doing this work about 15 years ago, 
hospitals 15 or 20 miles away from the Mass General Hospital in 
Boston were not treating with tPA because they did not have the 
availability of a stroke expert.
    It is very straightforward to provide the necessary 
information that you need at the bedside to make a diagnosis of 
stroke--review the brain scan, examine the patient, talk to the 
family, and make a decision with the bedside physician--with 
the technology we have available today.
    So the main barrier now is simply creating an environment 
where people feel there is no option, and stroke expertise must 
be available. This is a standard of care, and every hospital 
needs to be able to provide this basic evaluation. We would not 
accept the idea that you could come into a hospital with a 
heart attack and be told, ``Gee, I am sorry, we do not have a 
heart expert available. We will just have to send you to 
another hospital an hour away, and if you do not get treatment 
when you arrive there because it is too late, you know, I am 
very sorry.''
    We have to have that same attitude toward stroke. And this 
opening up of the geographic restriction, I think, will 
encourage many more hospitals to be able to initiate these 
kinds of services which are broadly available in the U.S. and 
in Europe.
    Senator Thune. In your testimony, you also noted the 
potential savings that can be found by investing in telestroke 
technologies instead of treating the last effects of stroke 
after the episode occurs.
    What are some of the issues faced by stroke survivors who 
do not receive timely care versus those who do, as well as the 
costs associated with those conditions?
    Dr. Schwamm. Well, you know, there are huge hidden costs of 
stroke on our society. I am sure many of the members have had a 
family member who has had a stroke. Patients become disabled, 
often cannot return to live at home. Or if they do live at 
home, they often need close to 24-hour care. Loved ones, 
spouses, children have to give up working or reduce their work 
in order to be available and help take care of their loved one.
    If people need chronic care and residential care, they 
often go through all their savings first and then end up on 
Medicaid and then end up in a nursing home chronically with 
frequent readmissions to the hospital for bedsores, for 
pneumonia, for urinary infections, for recurrent strokes. So it 
is a very, very debilitating disease. And as you know, it 
happens in an instant. Your life changes in an instant.
    The math is actually pretty simple, in the sense that we 
know that telestroke increases the use of tPA. That has been 
shown time and time again. We know that every treatment with 
tPA saves money, because it avoids long-term disability in a 
substantial portion of patients who receive it.
    A study back in the late 1990s estimated about $4,000 of 
savings per treated patient because of the reduced burden of 
this. And if you multiply that together with 500,000 Medicare 
beneficiaries who would be eligible for consultation if the 
restrictions were removed, you can see that savings are going 
to accrue.
    Now, whether they accrue to Medicare's budget, the State 
budgets, or to other payers, someone smarter than me will have 
to figure out, but it is just the right thing to do, to find a 
low-cost way of providing a treatment we know is effective and 
that we would encourage the hospital to do anyway if they had a 
stroke expert on hand.
    The cost of the telestroke consultation itself is trivial. 
Really what we are talking about is spending more money giving 
tPA to reduce long-term disability, which is the highest level 
of evidence recommendation of every major professional society.
    The Chairman. Senator, your time is up.
    Senator Thune. Mr. Chairman, I would just mention too, I 
want to associate myself--I understand that Senator Stabenow 
already talked about the Value-Based Insurance Design model 
demonstration, which is some legislation that we have worked 
on. And so I would think she has covered that base already. 
Thank you.
    The Chairman. Well, thank you, Senator.
    Senator Cardin?
    Senator Cardin. Thank you, Mr. Chairman. I want to thank 
you and Senator Wyden for bringing this hearing forward. And 
this is how we should be conducting our business: on a 
bipartisan basis and process. And I thank you, and I think it 
is going to lead to some good results and passage of 
legislation.
    I want to follow up on Senator Thune's point on telehealth. 
I have seen it firsthand in my State in Pocomoke City, a very 
rural part of Maryland where we have a VA facility, where they 
do not have the type of specialists that you would have in most 
communities. So ophthalmology is performed through telehealth, 
and it is working very, very well.
    On dealing with the stroke victims, we have three programs 
in Maryland working today, one in Carroll County, Westminster, 
a rural area, working with the University of Maryland. It is 
working very well. We have a program working in Hagerstown, 
which is also working well, in conjunction with a major center. 
So we have programs in our State that are performing extremely 
well.
    Also incorporated in this bill is how to deal with dialysis 
patients. With a stroke victim, saving the costs by reducing 
disabilities at the time of intervention is critically 
important. With a dialysis patient, it becomes a matter of cost 
and getting to a center and trying to have some degree of 
normalcy in your life. And to be able to do tele-examine so 
that a person can get care in their home can save a great deal 
for a family and make a person much more mobile.
    So my question to you is--this bill moves us forward in 
telehealth. But be a little visionary. Where do you see 
telehealth going? What can we look forward to doing, and what 
obstacles are in the way? And what concerns do we have as we 
move more towards a telehealth system so people can get more 
timely and more cost-efficient care?
    Dr. Schwamm, if you could start, and then if others have 
views, I would be curious as to where you see us going and what 
we need to change in order to be able to accommodate this type 
of health care.
    Dr. Schwamm. It is one of my favorite topics, so thank you 
for the question.
    Just briefly to comment on the dialysis issue, anything we 
can do to improve convenience to access will increase the 
delivery of those services and do so at a lower cost.
    We spend a huge amount of money on ambulance transport for 
dialysis patients to and from dialysis, for example. That is 
another hidden cost that could be dramatically reduced by using 
telehealth in these circumstances.
    My hope and my vision is that 10 years from now, 15 years 
from now, we will not be calling it telehealth, we will just be 
calling it health care. There is no reason why this artificial 
dichotomy, this false dichotomy of in-person versus virtual, is 
going to persist. Because we do not call it mobile banking and 
think about it as a completely different enterprise and have 
separate costs and decide that you cannot do certain 
transactions. Anything you can do that way saves everybody 
money, makes it more convenient, makes it more desirable.
    I really think we have to examine the health-care 
encounter, and there is more than one type, deconstruct it into 
its individual parts, and reassemble them in a way that is 
patient-centered, not doctor- or hospital-centered. If we do 
that right, we will figure out how to provide better care 
sooner, and we will be able to intervene upstream before 
diseases manifest themselves.
    We also have to fund research to make sure that what we 
decide to do is evidence-based and not simply what feels like 
the flavor of the day or what seems most attractive to 
consumers. We must be driven in this area just the way we are 
in medical care in general, which is by developing evidence and 
testing our hypotheses.
    We also do not want to create a new digital divide where we 
disenfranchise a new class of vulnerable people because they do 
not have access to technology in the same way. So these are all 
very important parts of really weaving telehealth into health 
care.
    Mr. Lovelace. If I could just build that out a minute, I 
think as you have heard earlier, starting with Senator Wyden's 
comments, the health-care system is really designed for the 
convenience of health-care providers, not for the convenience 
of users. And this is a move, I think--this sort of 
customization of health care to make services more accessible, 
more convenient, more timely--is a movement toward a more 
consumer-friendly model that will engage people in a better way 
to manage their care, especially chronic disease care over 
time, with improved access to quality standards.
    And I think telehealth, as to Dr. Schwamm's point, has the 
ability to allow for more monitoring of consistency of care and 
coordinated standards rather than what happens behind the door.
    Senator Cardin. I would be interested also if you believe 
that in the reimbursement structures there are certain areas 
that are particularly unfriendly towards advancing technology.
    Dr. Schwamm. I think the restrictions on State licensure 
and some of the regulations around billing and attestations as 
to whether the physician is licensed in the location where the 
patient is living are a barrier. I think it would make a lot 
more sense to require physicians to be licensed in the State 
where they are rendering care rather than where the patient is 
located.
    It is crazy that if a patient who lives in New Hampshire 
and sees me in the office in Boston every day for their care 
has a crisis and needs my help, that under the law I 
technically should not provide any medical advice to them if 
they call me from their home in New Hampshire. There is a lot 
of opportunity there, I think, to really rethink what it means 
to be licensed to practice medicine over telehealth.
    Senator Cardin. Thank you, Mr. Chairman.
    The Chairman. Well, thank you.
    Senator Cardin. Mr. Rosenthal, did you want to respond?
    Mr. Rosenthal. Well, I was just going to add to what Dr. 
Schwamm said. I think in the future, technology will be 
evolving so quickly that it will become a component of our 
everyday life. And I think making sure that we understand the 
impact of those tools on the health outcomes becomes important.
    So I think the opportunities are enormous. And I appreciate 
the committee's vision on that.
    The Chairman. Senator Bennet?
    Senator Bennet. Thank you, Mr. Chairman. And thank you and 
the ranking member for holding this important hearing and for 
your leadership over many years on chronic care issues.
    I also want to thank Senators Isakson and Warner for 
convening the chronic care working group. A lot of good work 
has been done there, and I think some thoughtful solutions 
about how to improve care for the sickest Medicare enrollees 
are coming to the fore now.
    Over 70 percent of health-care spending in the U.S. is 
linked to care for those with more than one chronic condition. 
And we have to improve care for those with diabetes, 
Parkinson's, and heart disease. These are our loved ones who 
are making multiple doctor visits, managing complicated 
instructions, and may need a caregiver to help with daily 
tasks.
    So, Mr. Lovelace, the Independence at Home Act would help 
improve care for patients while they are in the comfort of 
their own home. It would also reduce costs. I would like to 
thank Senators Portman, Markey, and Cornyn for their leadership 
on this bill, which would make the Independence at Home 
demonstration a national and permanent program.
    The Independence at Home model makes it possible for 
different health-care professionals to provide access to care 
24 hours a day, 7 days a week to beneficiaries with multiple 
chronic conditions.
    According to CMS, the Independence at Home payment model 
saved about $3,000 per participating beneficiary. And I am 
pleased to see an extension and expansion of the act included 
in the CHRONIC Care Act.
    If we were to go further and make this a national program, 
would programs at UPMC and those in my home State of Colorado, 
do you think, be able to serve even more chronically ill 
patients with higher quality and better, cost-effective care?
    Mr. Lovelace. Absolutely. We are fans of Independence at 
Home as a model. We have a version not quite exactly the same 
as Independence at Home that we employ in our health plan, with 
roving mobile care managers, nurses, social workers, nurse 
practitioners, who visit people on a regular basis. It provides 
much more ability to have eyes-on consistency managing chronic 
conditions as they begin to get worse rather than waiting until 
the emergency room. So we are definitely supportive of 
expansion of that act.
    Senator Bennet. Have you been able to measure cost savings 
in your own operation as a result?
    Mr. Lovelace. We do not really do Independence at Home as 
it is laid out in the bill. But in terms of our own efforts, it 
does produce significant reductions in unplanned care, 
certainly improvements in adherence to medication. People go in 
and measure out your pillbox. It has costs itself; it costs 
money. So I think on the whole, it is probably, while it saves 
a lot of unplanned money, it does cost money to do. It is kind 
of a break-even for us at this point.
    Senator Bennet. Dr. Schwamm, did you have something you 
would like to add?
    Dr. Schwamm. Yes. You know, I just was reflecting on your 
comment about Parkinson's disease. And if you go to a typical 
neurology clinic in this country and you have Parkinson's, you 
will probably be seen once every 6 months for 30 minutes. I 
would argue being seen for 5 minutes a day once a month over 
those 6 months to adjust your medications, to look for signs of 
worsening, would probably be time and money better spent and 
would save that poor family, you know, 60 to 70 hours of travel 
and recovery since the debilitating nature of the disease makes 
ambulation difficult.
    So there are better ways to spend even the dollars we are 
spending now.
    Senator Bennet. And that is actually a fascinating and very 
practical point. Why are we seeing somebody for--what are the 
disincentives to doing it the way that you describe?
    Dr. Schwamm. Well, the first would be that you do not get 
paid. So the system does not get paid; the doctor does not get 
paid. The patient spends a lot of money taking the day off from 
work or having a loved one come with them, driving, parking, 
waiting in the waiting room for, you know, 1 or 2 hours, not 
being able to see someone at night or at a time that is 
convenient for them.
    As was mentioned before, it is really doctor-centered care 
or 
hospital-centered care. Telemedicine, again--I think what we 
are seeing now is there is so much demand for this that we are 
seeing urgent care solutions and other things pop up in the 
cracks of our existing health-care system. But once the flood 
gates are open and we have reimbursement, I think you would see 
a tremendous amount of innovation and creativity at better 
meeting the needs of patients.
    Senator Bennet. Thank you for that.
    The CHRONIC Care Act that we are discussing today is taking 
important steps to increase care coordination for those who 
have multiple chronic conditions. We were just talking about 
some examples of that. For instance, it would allow Medicare 
Advantage plans to offer supplemental benefits designed for 
chronically ill beneficiaries, such as enhanced disease 
management.
    Medicare Advantage plans make sense for many seniors, as 
they align with their hospital, doctor, and prescription drug 
benefits. That is why I worked with Senator Portman on the 
Medicare Plus Act, which would enroll the top 15 percent of 
highest-cost Medicare beneficiaries into a Medicare Advantage 
plan or an Accountable Care Organization rather than a fee-for-
service plan.
    The plan or ACO can work with their doctors and hospitals 
to coordinate better their services and medications.
    What do you think we should keep in mind, to anybody on the 
panel, as we continue to work on our proposal and other 
proposals here to better coordinate care for the sickest and 
highest-cost patients? What are some unintended consequences we 
should try to avoid? And, you know, I think that you guys 
actually have today done us a lot of good by pointing out that 
not enough of the health-care system seems to be patient-
centric. It seems to be focused more on folks who are 
delivering the care. And we love the people who are, but really 
this is about the patient, having the patient not to have to 
fight the system to get the care they need when they need the 
care, so that in the end it is cheaper.
    I wonder if any of you sort of have a meta-observation 
about what we ought to keep in mind.
    Dr. Schwamm. I think the most important thing we have to 
understand when we move toward value-based purchasing and other 
measures is, what is the outcome of interest? Are we looking at 
cost? And if we say we are looking at quality, quality from 
whose perspective? Is it patient-reported outcomes and the 
things that matter most to patients? Or is it things that are 
just easy to measure because we can measure them in our claims 
data?
    So much work needs to be done to build these patient-
reported outcome measures that are meaningful, that are 
medically meaningful, and that can have costs tied to them so 
we can really monitor what we are doing.
    Senator Bennet. Does anybody else--I am sorry, Mr. 
Chairman; I realize I am out of time.
    The Chairman. That is all right. If you have anybody else 
who wants to comment----
    Mr. Lovelace. Just a brief comment. One of the great 
failures of the health-care system, I think, is blaming the 
patient for failure of compliance. And it is much more driven 
by people not being able to comply with what is instructed or 
not having enough understanding of what is suggested or not 
having the wherewithal to do that.
    So thinking more in the ACO, MCO version of what the 
partnership is, people who use services need to be engaged more 
actively rather than passively. So we sort of assume people 
will participate, and oftentimes, they would if they could, but 
they cannot.
    The Chairman. That is fine. You did fine.
    I have to say, as chairman of this committee, this has been 
one of the best panels we have ever had. I have not asked any 
questions. I used to be a medical liability defense lawyer, so 
I have dealt with a number of these problems. And you folks 
have really covered this about as well as I have ever heard it 
covered before. And I just want to commend you for it.
    Now, Senator Wyden has a question that he would like to 
ask.
    Senator Wyden. Thank you very much, Mr. Chairman.
    And I very much share your view with respect to this panel. 
I think that this is the Finance Committee at its best. I mean, 
this is tackling a big----
    The Chairman. I think it is the panel at its best myself.
    Sorry, I----
    Senator Wyden. I was giving you the credit for bringing 
them. All right.
    Let me ask about one other issue that we have talked a lot 
about in Oregon. You touched on it, I think, just sort of 
collaterally, you know, Ms. Hayes, and that is that a big part 
of our challenge here is that a lot of these patients with 
multiple chronic conditions face challenges that probably do 
not fit into the, quote, ``medical box,'' but clearly have 
ramifications for their health.
    I think someone mentioned access to transportation. 
Certainly the inability to get access to good nutrition affects 
diabetes.
    In our part of the world, people always talk about the fact 
that you may have a patient with heart problems and it is very 
hot and very humid, and they cannot get access to an air 
conditioner. And maybe a really cheap air conditioner would 
save enormous sums in terms of the person having to be 
hospitalized.
    And in effect, these are conditions that might not be, 
quote, ``technically medical'' but disproportionately hurt 
patients with multiple chronic conditions.
    So I think, Ms. Hayes, you were the one who touched on it. 
I think I would like to hear you just kind of describe, as we 
wrap up, what you think the role is for services that do not 
fit the classic box of being medical, but have enormous 
ramifications for a person's health.
    Obviously MA, the Medicare Advantage program, has tried to 
incorporate some of that. But as we wrap up what the chairman 
has correctly said has really been an exceptional panel, we are 
counting on all of you to stay with us as we try to move this 
across the finish line.
    I think sometimes, as I have talked to people, people have 
said, excuse me, Ron, you are going to pass a major Medicare 
bill in this kind of climate? And I said that we have put a lot 
of work into this. We have a good cross-section of the Senate 
represented on this committee. So we are going to be calling on 
you for your help as we try to get this across the finish line.
    And just to wrap up, if you would, for me, Ms. Hayes, give 
us your sense of what we ought to be doing for the long term as 
it relates to treatment for these services that do not probably 
fit the classic box.
    You know, people always say to me, in health, the costs 
find coverage, that this is like an aphorism. Well, that sounds 
like it is pretty good for the provider, but it probably is not 
so great for the patient.
    What would you do for the patients in the area that we are 
talking about, the classic being the air conditioner for 
somebody who has a heart problem and could be helped out with 
modest costs?
    Ms. Hayes. I think one of the most important components of 
this legislation is that you are allowing plans or allowing 
reimbursement models that are working under a benchmark or a 
capitation system to cover anything that is reasonably related 
to improving or maintaining health and functional status so 
long as it is part of a care plan developed by a care team.
    And this allows providers to sit down with patients, with 
family members, with their caregivers, and really talk to them 
about what they need and base their care plan on what they need 
rather than what the Medicare program covers.
    And you know, someone has suggested to me, actually one of 
my staff at one point said to me, are you telling me that you 
would allow Medicare to cover a dog-walking service? And I 
said, well, you know, if a plan working under a capitated 
system determines that it is better to bring in a dog walker 
for grandma on a day when there is 6 inches of snow on the 
ground to avoid a hip fracture, maybe we should consider that 
so long as it is within that payment model and it is to the 
benefit of the plan to provide these services.
    Senator Wyden. Why don't we do this? I know Senator Warner 
has additional comments.
    Could you furnish us two or three of the models that you 
think have been particularly good at picking up on this area 
that I am talking about, the services that do not technically 
fit what would be called the medical condition? Could you just 
furnish that for us?
    Ms. Hayes. Yes, I will be happy to.
    Senator Wyden. Thank you, Mr. Chairman.
    The Chairman. Well, thank you.
    Senator Warner, you will be the last one.
    Senator Warner. Thank you, Mr. Chairman. I appreciate that 
and recognize sometimes when a member comes in after a long 
hearing--I will try not to take my whole 5 minutes, but I want 
to at least----
    The Chairman. That will be great. [Laughter.]
    Senator Warner. I want to start, though, by thanking you 
and the ranking member and also for the wisdom of appointing 
Johnny Isakson to serve on this effort as well.
    I think, echoing what Senator Wyden said, we have a great 
product here. You know, it may not be the whole enchilada, but 
it is an area where we can find common ground. And I would 
commend both of you and commit anything I can do to assist 
getting it over the finish line.
    I believe not only in the value of this product, but the 
value of showing that even in these challenging times, this 
committee on this challenging subject can move a product. Count 
me 100-percent in in any way I can help.
    The Chairman. Thank you, Senator Warner. We appreciate 
that.
    Senator Warner. Let me just very briefly, Ms. Hayes, ask 
two very brief questions. One, two parts of the bill that I 
particularly like, having been a former Governor--and candidly 
I could probably get comments from everybody, but I will just 
go to Ms. Hayes on this--but the challenge with dual-eligibles 
and the challenge with folks who kind of float between Medicare 
and Medicaid is the amount of time it takes to qualify or 
requalify for one program after another. You know, we do have 
an appeals process, a streamlined appeals process for 
grievances, in this legislation. To my mind, that is a great 
step forward. Do you want to make a comment on that?
    Ms. Hayes. Sure. I think that has been one of the major 
challenges of the existing financial alignment initiative 
demonstrations, because of the differences in Medicare and 
Medicaid laws. And I think that will move forward.
    One of the most promising things that has come out of this 
demonstration is the concept of a three-way contract in which a 
State can sit down with CMS and a plan and negotiate a contract 
to provide services with uniform requirements between the 
Medicare and Medicaid program so you do not have patients 
working with--it is bad enough to be 78 years old and have 
Medicare, but to be 78 years old and have Medicare and Medicaid 
when the program rules do not align----
    Senator Warner. Right. Well, that goes back to--we had 
those issues back when I was Governor.
    There is one final point I just want to raise. I mean, 
Senator Isakson and I--and he has been a great partner, again--
have championed a long time the Care Planning Act and this 
whole question about not limiting by any means anyone's 
choices, but expanding choices and trying to urge families to 
sit down with their caregivers, with their religious figures, 
with medical personnel, and really just kind of think through 
the part of life that we are all going to go through.
    Increasingly, you know, we have gotten a lot of folks with 
lots of chronic illnesses who also have cognitive impairments. 
And one of the things that our bill does is introduce a GAO 
study to identify barriers to care planning that would take 
place, particularly for folks who have these chronic illnesses 
and chronic impairments.
    I know, again: do as I say, not as I did, because I was a 
relatively well-informed individual, I was a Governor of 
Virginia, but we did not sit down and have those conversations 
with my mom before it was too late for her to participate.
    So I think this is, again, an important step forward. I 
appreciate the chairman's and the ranking member's support of 
this provision. But a quick comment on that and then I will 
sign off.
    Ms. Hayes. Sure. And I think the way you have structured 
it, the way you have structured reimbursement, would allow a 
care team to sit down and talk to the family member. My mother 
was just discharged from the hospital, and they asked if she 
had a care plan. They gave her one going in and going out, and 
she was not educated on this and she was afraid and did not 
understand what they wanted her to do. But telling her, mom, 
you know, I have a care plan, an advanced care plan, this is 
really something that is important. And it benefits not only 
the patients, but their families who have to make such a 
terrible decision.
    Senator Warner. And I would simply close out by saying, 
again, Mr. Chairman and Ranking Member, we ought to prove the 
cynics wrong and get this legislation passed. Thank you for 
your great work.
    The Chairman. Well, thank you. And we appreciate your 
support.
    We really appreciate the four of you. You have been 
wonderful witnesses on what we consider to be a very, very 
bipartisan discussion. And we intend to get this bill through. 
And I think you have made our lives a little better in getting 
it through because of the excellent testimony you have brought 
here today. So I just want to personally thank each and every 
one of you.
    I have not asked any questions, because I wanted everybody 
else to have the opportunity to. But I have listened carefully, 
and all I can say is, you have done a great job and you have 
represented an awful lot of wonderful people in ways that they 
have not been represented before. So we are grateful to have 
you here.
    And with that, we are going to recess until further notice.
    [Whereupon, at 11:48 a.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


              Prepared Statement of Hon. Orrin G. Hatch, 
                        a U.S. Senator From Utah
WASHINGTON--Senate Finance Committee Chairman Orrin Hatch (R-Utah) 
today delivered the following opening statement at a hearing to examine 
the Creating High-Quality Results and Outcomes Necessary to Improve 
Chronic (CHRONIC) Care Act of 2017 and ways to improve health outcomes 
for patients living with chronic illnesses:

    I'd like to welcome everyone to this morning's hearing on 
bipartisan Medicare policies to improve care for patients with chronic 
conditions.

    It was almost exactly 2 years ago today that we formed a bipartisan 
working group co-chaired by Senators Isakson and Warner to work on 
legislation to address these issues.

    That working group spent many months listening to stakeholders in 
the health-care community--both in person and through more than 850 
formally submitted comments.

    In December of 2015, the working group released a comprehensive 
policy options document.

    In October of last year, we issued a legislative discussion draft. 
Soon after that, CMS finalized four of our policy proposals in its 2017 
Medicare Physician Fee Schedule Rule. And, two provisions from our 
discussion draft were included in the 21st Century Cures Act, which 
President Obama signed into law this past December.

    In other words, several of the working group's policies have 
already been enacted, and we're working to get the rest signed into law 
and fully implemented.

    Toward that end, we introduced the latest version of the CHRONIC 
Care Act--the bill that encompasses the working group's proposals--in 
April. The legislation currently has 17 bipartisan cosponsors and has 
been endorsed by numerous organizations in the health care community.

    Today's hearing is the latest step in our efforts. The next step 
will come later this week, as we've noticed a markup for Thursday 
morning.

    I want to thank Ranking Member Wyden for his work on this matter. 
His passion for improving care for those with chronic conditions has 
been a driving force behind this effort.

    And, of course, I want to thank Senators Isakson and Warner, who 
have worked tirelessly to lead our working group. Through their 
efforts, the committee has not only learned about the burden imposed on 
Medicare patients living with chronic conditions, but also identified 
new policies to improve care coordination, increase value, and lower 
costs in the Medicare program without adding to the deficit.

    Today's hearing will provide us with an opportunity to examine 
these policies more extensively so we can better understand how they 
will help patients and enable providers to improve care and produce 
better outcomes.

    The bill includes a number of policies that would improve care for 
the chronically ill through increased use of telehealth, by giving 
Medicare Advantage plans and certain Accountable Care Organizations 
enhanced flexibility to target telehealth services to Medicare patients 
with chronic conditions.

    Senators Schatz and Wicker have been instrumental in this 
particular effort and I am pleased to have them here with us to talk 
about how the CHRONIC Care Act advances their policy goals.

    I would be remiss if I did not also recognize the Finance Committee 
members who have joined Senator Schatz and Senator Wicker's efforts to 
promote the increased use of telehealth services. In that regard, we 
appreciate the leadership of Senators Thune, Cardin, and Warner on 
these matters.

    While many stakeholders offered key advice on telehealth policy, I 
want to thank the fine institutions in Utah for their help, 
specifically on the ``telestroke'' policy. Specifically, I want to 
recognize Dr. Jenny Majersik and Dr. Nicholas Johnson at the University 
of Utah as well as Dr. Kevin Call with Intermountain Healthcare. I 
appreciate their willingness to share their experience and expertise 
using technology to promptly diagnose individuals presenting stroke 
symptoms, and I look forward to hearing more on this particular aspect 
of telehealth here today.

    Of course, our bill goes beyond telehealth, making improvements for 
beneficiaries who receive care across the Medicare spectrum, including 
fee-for-service, Accountable Care Organizations, and Medicare 
Advantage.

    We have a panel of recognized experts here before us today to 
discuss all of these issues and I want to welcome each of our 
distinguished witnesses.

    Obviously, I'm well aware that there are some contentious debates 
going on in the health-care space these days and there is no shortage 
of political and partisan points that people would like to make in a 
venue like this. However, for today's hearing, I sincerely hope that we 
can maintain the bipartisan spirit that has driven our efforts on the 
CHRONIC Care Act. Toward that end, I respectfully ask that members of 
the committee focus their questions on the policy areas specifically 
addressed in the bill.

                                 ______
                                 
          Prepared Statement of Katherine Hayes, Director of 
                Health Policy, Bipartisan Policy Center
    Chairman Hatch, Ranking Member Wyden, Senators Isakson and Warner, 
and members of the committee, thank you for the opportunity to discuss 
important policy changes that can help health-care providers and health 
plans improve health outcomes for chronically ill patients. The 
committee's work in drafting the Creating High-Quality Results and 
Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 
demonstrates that bipartisanship in health care is not a thing of the 
past. These policies address the unique needs of chronically ill 
patients and promotes patient and family-centered care. The Chronic 
Care Working Group's bipartisan, transparent, and deliberative process 
of seeking feedback and an ongoing dialogue with the stakeholder and 
patient community should serve as the model for smart policy 
development in Congress. The Bipartisan Policy Center greatly 
appreciated the opportunity to share our input with the Working Group 
as part of that thorough process.

    Since 2007, BPC's Health Project has worked with stakeholders 
including patients, health-care providers, plans, States, and Federal 
policymakers to develop solutions that to promote better quality of 
care, while limiting the growth of health-care costs in Federal health 
programs. Under the leadership of the Health Project's Co-Chairs, 
former Senate Majority Leaders Bill Frist and Tom Daschle, BPC has 
released a series of reports and policy recommendations to address 
acute care and long-term care needs of frail and chronically ill 
individuals. On our efforts in long-term care delivery and financing, 
former White House and Congressional Budget Office Director Alice 
Rivlin and former Health and Human Services Secretary and Governor 
Tommy Thompson co-chaired the efforts.

    In February 2016, BPC issued incremental recommendations on 
policies to improve long-term care financing. Last fall, we released a 
report focused on better integration of Medicare and Medicaid services 
and supports for individuals who are dually eligible for Medicare and 
Medicaid coverage.\1\, \2\ Last month, BPC issued a report 
that provides recommendations to remove barriers that health plans and 
providers face as they seek to treat chronically ill Medicare 
beneficiaries.\3\
---------------------------------------------------------------------------
    \1\ Bipartisan Policy Center, ``Initial Recommendations to Improve 
the Financing of Long-Term Care,'' February 2016. Available at: https:/
/bipartisanpolicy.org/library/long-term-care-financing-recommendations/

    \2\ Bipartisan Policy Center, ``Delivery System Reform: Improving 
Care for Individuals Dually Eligible for Medicare and Medicaid,'' 
September 2016. Available at: https://bipartisan
policy.org/library/dually-eligible-medicare-medicaid/.
    \3\ Bipartisan Policy Center, ``Improving Care for High-Need, High-
Cost Medicare Patients,'' April 2017. Available at: https://
bipartisanpolicy.org/library/improving-care-for-high-need-high-cost-
medicare-patients/.
---------------------------------------------------------------------------
               care needs of chronically ill individuals
    Research conducted by BPC and others makes clear that the presence 
of chronic conditions, particularly when paired with functional or 
cognitive impairment, is a key driver of utilization of medical 
services for Medicare beneficiaries. Medicare data from 2015 
demonstrate that the number of chronic conditions that a patient has is 
directly correlative to higher Medicare spending and rates of 
hospitalization--as the number of chronic conditions rise, so do 
average Medicare costs per beneficiary.\4\
---------------------------------------------------------------------------
    \4\ Centers for Medicare and Medicaid Services, ``Multiple Chronic 
Conditions,'' CMS Database of 2015 Data on Chronic Condition Prevalence 
and Medicare Service Utilization Statistics, Accessed May 3, 2015. 
Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/
Statistics-Trends-and-Reports/Chronic-Conditions/MCC_Main.html.

    For instance, compared to beneficiaries with fewer than four 
chronic conditions, the Medicare beneficiaries who have four or more 
---------------------------------------------------------------------------
chronic conditions:

          Incur average annual Medicare costs that are more than five 
        times as high;

          Have hospital readmission rates that are twice as high; and

          Have four times as many emergency department visits.

    The presence of functional and cognitive limitations among 
chronically ill beneficiaries is also highly predictive of Medicare 
costs. Functional impairments are defined by difficulty in performing 
activities of daily living, such as bathing or transferring to and from 
bed without assistance.\5\ Cognitive impairments can include diminished 
intellectual capacity associated with dementia or Alzheimer's disease, 
which can present safety concerns for patients.\6\ Medicare patients 
with functional or cognitive impairment have expenses that are more 
than three times as high as those without functional or cognitive 
impairment.\7\
---------------------------------------------------------------------------
    \5\ Sally Rodriguez, Diane Munnevar, Caitlin Dulaney, et al., 
``Effective Management of High-Risk Medicare Populations,'' Avalere LLC 
and SCAN Foundation Report, September 2014. Available at: http://
avalere.com/news/avalere-issues-white-paper-on-the-management-of-high-
risk-medicare-populati.
    \6\ Ibid.
    \7\ Ibid.

    BPC's research indicates that there are roughly 3.6 million 
community-residing ``Medicare-only'' beneficiaries (i.e., beneficiaries 
are not eligible for full Medicaid benefits) who have three or more 
chronic conditions and functional or cognitive impairment. In addition, 
there are roughly 7.5 million Medicare beneficiaries who are dually 
eligible for full Medicaid benefits. The two populations have complex 
needs for services and social supports to address their multiple 
chronic conditions, frailty, and cognitive deficits. For dual-eligible 
beneficiaries, Medicaid covers many of the long-term services and 
supports (LTSS) that the beneficiary needs, but the LTSS is often not 
well integrated with medical care covered under Medicare. For frail and 
chronically ill Medicare-only individuals, the supports and services 
are not covered under Medicare, although they could be made available 
if there were more flexibility and financial incentives for Medicare 
---------------------------------------------------------------------------
Advantage (MA) plans and health-care providers.

            policies to improve integration of medicare and 
            medicaid benefits for dual-eligible individuals
    In its September 2016 report, BPC made several recommendations to 
reform Dual-Eligible Special Needs Plans (D-SNPs) within the MA 
program, and to consolidate regulatory authority within the Centers for 
Medicare and Medicaid Services (CMS) for policies applicable to dual-
eligible beneficiaries.\2\ Most of these recommendations are very 
similar or consistent with the CHRONIC Care Act.

    Specifically, among other recommended policies in the report, we 
recommended:

          Permanently reauthorizing D-SNPs, but requiring that D-SNPs 
        integrate clinical health services, behavioral health, and LTSS 
        by January 1, 2020;

          Authorizing CMS to align the Medicare and Medicaid grievance 
        and appeals processes for D-SNPs in a manner that benefits the 
        dual-eligible individual; and

          Consolidating regulatory authority for reimbursement 
        structures serving dual-eligible beneficiaries into a single 
        office or center within CMS, such as the Medicare-Medicaid 
        Coordination Office.

    These changes will break down the financial siloes between Medicare 
and 
Medicaid-covered services to allow for an integrated approach to 
meeting a D-SNP enrollee's medical needs and LTSS needs, while also 
making the navigation of benefits more manageable for D-SNP enrollees. 
The CHRONIC Care Act's policy provision to make the Medicare-Medicaid 
Coordination Office the central contact point for aligning Medicare's 
Federal grievance and appeals processes with the corresponding 
processes of State Medicaid programs would minimize conflicting overlap 
between the two programs.

    These three policy changes--when combined with other BPC 
recommendations for improving three-way contracting models for the 
delivery of Medicare and Medicaid benefits--can enhance the ability of 
health plans and providers to meet the medical and non-medical needs 
for dual-eligible beneficiaries. By financially and clinically 
integrating Medicare-covered services with Medicaid social support and 
LTSS benefits, we can improve health outcomes of dual-eligible 
beneficiaries through a reduction in avoidable hospitalizations, 
emergency department visits, and hospital readmissions, particularly 
for patients with complex chronic conditions, as shown in a recent 
report examining the Senior Health Options program in Minnesota.\8\
---------------------------------------------------------------------------
    \8\ Department of Health and Human Services Assistant Secretary for 
Planning and Evaluation. Minnesota Managed Care Longitudinal Data 
Analysis. March 2016. Available online at: https://aspe.hhs.gov/report/
minnesota-managed-care-longitudinal-data-analysis.

policies to break down barriers to integrating social supports in care 
   models serving medicare-only beneficiaries with chronic illnesses
    As a part of an April 2017 report, BPC recommended policies 
designed to improve the ability of MA plans, Accountable Care 
Organizations (ACOs), and other alternative payment model (APM) 
participants to furnish and finance valuable non-
Medicare-covered supports and services for frail and chronically ill 
Medicare-only patients.\3\

    Among other recommendations, BPC recommended the following policy 
changes that are very similar to changes proposed under the CHRONIC 
Care Act:

          Modifying the MA ``uniform benefit requirement'' to allow MA 
        plans to target non-Medicare-covered social supports, as MA 
        supplemental benefits, to certain high-need, high-cost 
        Medicare-only enrollees with chronic conditions;

          Allowing MA plans that target non-Medicare-covered supports 
        to chronically ill enrollees to have an exemption from the MA 
        program rules that limit the coverage of supplemental benefits 
        to only those services and items that are ``primarily health-
        related''; and

          Establishing a prospective voluntary enrollment process in 
        the Medicare Shared Savings Program (MSSP) for ACOs, through 
        which beneficiaries can actively choose to have their care and 
        spending attributed to a specific ACO.

    These policy changes and others included in BPC's April 2017 policy 
recommendations can help to modernize the Medicare program in response 
to evidence showing that non-Medicare-covered supports can play a 
critical role in improving health outcomes.\3\ A growing body of 
research demonstrates that the provision of non-medical social supports 
and services, which are not covered under the traditional Medicare 
benefit, can reduce hospitalizations, emergency department visits, and 
other expensive acute care episodes when the supports are targeted to 
frail and chronically ill patients. Examples include non-emergency 
transportation to medical appointments for frail individuals or home 
delivery of nutritious, low-sodium and low-sugar meals for patients 
with congestive heart failure, diabetes, and other chronic conditions. 
In pilot programs tested in the community, the provision of these 
targeted non-medical supports resulted in as high as a 27 percent 
reduction in medical costs and significant reductions in avoidable 
hospitalizations.\9\ Other interventions, such as minor home 
modifications to reduce the risk of falls,\10\ or targeted case 
management to help coordinate a patient's medical and social support 
needs, have also been shown to improve health outcomes.\11\
---------------------------------------------------------------------------
    \9\ Jill Gurvey, Kerry Rand, et al., ``Examining Health Care Costs 
Among MANNA Clients and a Comparison Group,'' Journal of Primary Care 
and Community Health, June 2013. Available at: http://www.mannapa.org/
wp-content/uploads/2014/07/MANNA-Study.pdf; See also Joseph J. Cronin, 
``Florida Transportation Disadvantaged Programs: Return On Investment 
Study,'' Florida State University College of Business, March 2008. 
Available at: http://tmi.cob.fsu.edu/roi_final_report_0308.pdf.
    \10\ Bipartisan Policy Center, ``Healthy Aging Begins at Home,'' 
May 2016. Available at: https://bipartisanpolicy.org/library/
recommendations-for-healthy-aging/.
    \11\ Lauren A. Taylor, Caitlin E. Coyne, et al., ``Leveraging 
Social Determinants of Health: What Works?'', Blue Cross Blue Shield 
Foundation of Massachusetts, June 2015. Available at: http://
bluecrossfoundation.org/sites/default/files/download/publication/
Social_Equity_Report_Final.
pdf; See also Roy Ahn, ``Health Care Innovation Awards Complex/High-
Risk Patient Targeting: Third Annual Report,'' 143, NORC at the 
University of Chicago Report Commissioned by the CMS Center for 
Medicare and Medicaid Innovation, February 2017. Available at: https://
downloads.cms.gov/files/cmmi/hcia-chspt-thirdannualrpt.pdf.

    Despite the clear value of many non-Medicare-covered social 
supports in reducing the risk of avoidable Medicare expenses, the 
Medicare program has established regulatory and payment policy barriers 
that limit the ability of MA plans, ACOs, and other APM participants to 
integrate non-Medicare-covered supports into their care models for 
high-need, high-cost Medicare-only patients. If a health plan or 
provider organization is accountable for the quality of care provided 
to a beneficiary population and is accepting financial risk by working 
within a spending benchmark, the Medicare program should provide 
flexibility to allow the MA plans and providers that meet quality 
thresholds to furnish non-Medicare-covered supports in a targeted way 
to frail and chronically ill Medicare-only beneficiaries, as a part of 
a person- and family-centered care plan for frail chronically ill 
Medicare-only patients. Our recent work and policy recommendations from 
the April 2017 report make clear that with these flexibilities, the MA 
plans, ACOs, and other providers could make these non-Medicare-covered 
supports available to targeted beneficiaries in a manner that does not 
add new costs to the Medicare program.
Medicare Advantage Policies
    In the MA program, there are two principal regulatory barriers that 
prevent MA plans from financing high-value non-Medicare-covered social 
supports for targeted groups of chronically ill enrollees. First, the 
Social Security Act requires that if an MA plan offers a supplemental 
benefit that is financed through MA rebate dollars, the MA plan must 
offer that supplemental benefit to all enrollees--and may not, in most 
cases, target the supplemental benefit to subsets of enrollees who meet 
eligibility criteria. Second, MA program regulations and guidance 
require that supplemental benefits must be ``primarily health-
related''--a distinction that often leads to uncertainty for plans 
seeking to offer non-Medicare-covered social supports as supplemental 
benefits. These regulations and guidance policies also place specific 
restrictions on the ability of MA plans to offer certain types of 
supplemental benefits, such as a durational limitation on the offer of 
in-home meal delivery and a limitation on the availability of minor 
home modification benefits to only include shower and bathroom-related 
modifications. In combination, these two policy barriers can often 
prevent MA plans from tailoring supplemental benefit offerings to meet 
the needs of the specific chronically ill enrollee.

    BPC conducted an analysis of the projected costs of offering an 
illustrative set of non-Medicare-covered social supports to Medicare-
only MA enrollees who resided in the community and had three or more 
chronic conditions and functional or cognitive impairment. BPC's 
recommendations aim to provide the flexibility for patients to receive 
non-Medicare-covered supports and services as part of a care plan 
developed by providers and care teams in consultation with patients and 
their families. For this population, BPC recommended allowing coverage 
of ``any item or service reasonably related to improving or maintaining 
health or functional status, if the services are part of that care 
plan. To facilitate estimating costs of providing these types of 
services and supports, we projected the costs of in-home meal delivery, 
non-
emergency medical transportation, minor home modifications, and 
targeted case management services.

    The analysis suggests that if the uniform benefit requirement were 
waived, in conjunction with flexibility on the ``primarily health-
related'' benefit requirement, MA plans could offer the four 
illustrative non-Medicare-covered supports--to chronically ill 
enrollees who meet the criteria--as supplemental benefits within 
current budgets that do not require additional Medicare spending. BPC's 
analysis indicates that if the four non-covered supports were targeted 
to chronically ill enrollees and the costs of providing those services 
were spread across the entire enrollee population, MA plans could 
provide those four supports for merely $5 per member per month. If the 
provision of these non-Medicare-covered social supports reduced 
hospitalizations, emergency department visits, and other Medicare 
spending for the targeted group of enrollees, there is also a potential 
for savings.
Accountable Care Organization Policies
    Many ACOs report that the lack of a voluntary enrollment pathway 
for beneficiaries contributes to significant year-to-year fluctuations 
in the makeup on an ACO's attributed beneficiary population (for whom 
the ACO is assuming financial risk), while simultaneously impeding 
improved patient engagement in the care process by beneficiaries who 
ultimately are attributed to the ACO. While the Next Generation ACO 
demonstration includes a voluntary enrollment option, voluntary 
enrollment is not currently available for most ACOs operating in the 
MSSP. This problem not only inhibits the ability of ACOs to better 
coordinate the delivery of 
Medicare-covered services that a beneficiary receives, but also 
provides a strong disincentive for ACOs to invest in non-Medicare-
covered supports for attributed beneficiaries with chronic conditions 
and frailty. While providing these non-covered supports and services 
can improve health outcomes over the long-term, beneficiaries may not 
be attributed to the ACO year after year. When a beneficiary is aware 
that he or she is being cared for under an ACO arrangement and actively 
selects that ACO, there is greater potential for coordination between 
the patient and the care team. For these reasons, BPC recommended that 
CMS establish a voluntary enrollment option for all ACOs, in a manner 
similar to the proposal included in the CHRONIC Care Act.
Other Policy Options for Both MA Plans and ACOs
    In addition to the policies included in the CHRONIC Care Act, BPC 
also recommended policies that could improve financial incentives for 
both MA plans and ACOs to provide non-Medicare-covered supports to 
their enrolled or attributed beneficiaries. These recommendations could 
be addressed by CMS, without additional statutory changes from 
Congress, and could augment the great work of the committee on the 
CHRONIC Care Act. The recommendations are also similar to options that 
the committee included in its Chronic Care Working Group Options Paper. 
Among other options, BPC recommended that CMS test the potential for 
incorporating a frailty adjustment factor into the Medicare risk 
adjustment model that is used for the MA and ACO programs. Such a 
frailty factor could address significant under-prediction of the actual 
medical expenses of the highest cost beneficiaries, while also better 
accounting for the costs of beneficiaries with functional impairment. 
With more accurate risk adjustments for frail patients, MA plans and 
ACOs would have greater incentive to integrate non-Medicare-covered 
supports into care models for chronically ill beneficiaries. BPC also 
recommended that CMS examine options for adding a new quality measure 
to the MA and ACO quality measurement programs that would assess the 
extent to which the MA plan or ACO actively integrates non-Medicare-
covered supports into the care model for chronically ill beneficiaries. 
Given that MA quality bonuses and higher ACO sharing rates are tied to 
quality measure performance, MA plans and ACOs could have a strong 
incentive to incorporate non-Medicare-covered supports into their care 
models, in response to the new quality measure. If done well, this 
could also remove incentives for plans to avoid the sickest 
beneficiaries.
                               conclusion
    BPC applauds the hard work that the committee and its Chronic Care 
Working Group have taken to develop thoughtful bipartisan legislation 
to better address the needs of Medicare beneficiaries with complex 
chronic conditions. Through the policy changes included in the CHRONIC 
Care Act, many frail and chronically ill Medicare patients could 
benefit from improved care coordination, access to care in the home and 
community setting, and availability of non-Medicare-covered social 
supports. We appreciate the opportunity to continue to work with the 
committee in confronting the health care delivery system challenges 
facing this vulnerable population.

                                 ______
                                 
Prepared Statement of John G. Lovelace, President, Government Programs 
 and Individual Advantage; and President, UPMC for You, UPMC Insurance 
 Services Division, UPMC Health Plan, University of Pittsburgh Medical 
                                 Center
    Chairman Hatch, Ranking Member Wyden, Senator Casey, Senator 
Toomey, and members of the committee, on behalf of UPMC Health Plan and 
the over 3 million people we serve, primarily Pennsylvanians, thank you 
for the opportunity to testify today on S. 870, the Creating High-
Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) 
Care Act of 2017. We are proud to support this legislation and grateful 
for the opportunity to discuss the critical issues of care coordination 
and improved health-care services for Medicare beneficiaries with 
chronic care needs.

    By way of background, UPMC Health Plan and the integrated companies 
of the UPMC Insurance Services Division (collectively, ``UPMC'') are 
pleased to submit the following comments on Medicare policies that 
improve care for patients with chronic conditions, including those 
advanced by the Creating High-Quality Results and Outcomes Necessary to 
Improve Chronic (CHRONIC) Care Act of 2017 (S. 870).

    UPMC Health Plan and the UPMC Insurance Services Division are part 
of the University of Pittsburgh Medical Center health system (the 
``UPMC System''), an Integrated Delivery and Financing System (IDFS) 
that combines comprehensive 
provider-led clinical practice with a value-driven payer model to align 
payer-
provider financial incentives and promote higher quality outcomes for 
patients. The UPMC System includes more than 25 hospitals, 600 
affiliated physician and outpatient office sites, 3,600 employed 
physicians, and international clinical partnerships in 12 countries. 
UPMC System hospitals were recently named to the U.S. News and World 
Report Honor Roll of America's Best Hospitals, and are ranked 
nationally in 15 specialties. The UPMC System is also closely 
affiliated with the University of Pittsburgh, which has been among the 
top 10 recipients of National Institutes of Health research funding 
since 1998; in collaboration with the University's Schools of Health 
Sciences, the UPMC System provides ongoing education and training to 
nearly 1,800 medical residents and clinical fellows, as well as an 
average of 500 nurses per academic semester.

    UPMC is pleased to offer a full range of commercial individual and 
group health insurance, Medicare Advantage (MA), Medicare Special Needs 
Plans (SNP), CHIP, Medicaid, behavioral health, dental, vision, 
employee assistance and workers' compensation coverage products. Our MA 
plan, UPMC for Life, serves approximately 160,000 members combined 
through the MA Part C/D and SNP programs. Through our Medicaid managed 
care organization, UPMC for You, we provide coverage to more than 
400,000 enrollees across 40 Pennsylvania counties, and our behavioral 
health managed care organization, Community Care Behavioral Health, 
manages mental health and substance abuse services for almost 1 million 
Medical Assistance enrollees in Pennsylvania. In January 2018, UPMC 
will expand its portfolio to include Pennsylvania's Community 
HealthChoices, a Managed Long-Term Services and Supports (MLTSS) 
program that is expected to serve more than 360,000 individuals who are 
disabled, placed in nursing homes, or dually eligible for Medicare and 
Medicaid. We will be rolling this program out across Pennsylvania 
through 2018 and will complete that roll out in 2019. Since beginning 
operations in 1996, UPMC's Insurance Services division has been 
recognized multiple times for its dedication to quality and the 
provision of outstanding customer services across its product lines, 
which collectively provide commercial or government programs coverage 
to more than 3 million members.

    We thank Chairman Hatch, Ranking Member Wyden, and all the members 
of the Senate Committee on Finance (the committee) for the opportunity 
to comment on ways in which the Medicare program can improve care for 
patients with chronic illness. We applaud the Chronic Care Working 
Group's ongoing efforts to improve the quality and integrity of the 
Medicare program for those beneficiaries living with chronic 
conditions, and support the recent re-introduction of the CHRONIC Care 
Act in furtherance of those efforts. We previously submitted comments 
in response to the Working Group's 2015 chronic care ``Policy Options'' 
document (see January 29, 2016 letter), and we sincerely thank the 
Working Group for both their consideration of our input and their 
continued dedication to solving the challenges of serving chronically 
ill Medicare beneficiaries. We share the committee's belief that better 
care coordination, appropriately tailored and aligned incentives, and 
new and innovative policies designed to improve overall care delivery, 
manage costs, and foster improved outcomes will positively impact both 
Medicare beneficiaries and our Nation's efforts to responsibly control 
the ever-escalating cost of medical care. It is with this support and 
shared belief in mind that we respectfully offer for the committee's 
consideration the following comments.
      i. permanent authorization for medicare special needs plans
    Since their creation in 2003, Special Needs Plans (SNPs) have grown 
significantly and now provide targeted coverage and support to more 
than 2 million of the most vulnerable Medicare beneficiaries. While 
SNPs were originally established on a temporary basis, Congress has 
repeatedly recognized the value of SNPs as part of the Medicare 
program, and has consistently found cause to extend authorization for 
SNPs over the past 14 years; today, there are more than 500 SNPs 
operating nationwide. The story of SNPs is one of success for both the 
Medicare program and the beneficiaries it serves, and the fundamentally 
individualized nature of SNP coverage means that every beneficiary 
enrolling in the program is likely to receive better tailored and more 
coordinated services than he or she would otherwise have in fee-for-
service Medicare or the broader Medicare Advantage program. UPMC has 
long been committed to serving beneficiaries in Special Needs Plans 
(SNPs) by offering high quality, cost-effective SNP products that place 
a strong emphasis on care management and service coordination. UPMC 
currently provides coverage to more than 22,000 dually eligible 
Medicare members through UPMC for Life Dual, among the largest stand-
alone 4-Star dual eligible SNPs (D-SNP) in the Nation and the 17th 
largest D-SNP overall. We remain committed to continue serving the 
vulnerable SNP population, and we thank the sponsors of the CHRONIC 
Care Act for once again recognizing the critical importance and value 
of the SNP program.

    Section 201 of the CHRONIC Care Act would permanently authorize I-
SNPs, D-SNPs, and C-SNPs, and would impose certain additional 
conditions on SNP contracts to promote service integration and improve 
coordination. We enthusiastically support the permanent authorization 
of SNPs. Plans and States, and by extension beneficiaries, rely upon 
the continued availability of SNPs when planning for their future. 
States are particularly sensitive to uncertainty in funding or 
authorization for SNPs; the program integration that is necessary to 
truly realize the value and effectiveness of SNPs requires significant 
administrative effort and long-term investment in Medicare-Medicaid 
coordinating activities. Faced with uncertainty regarding continued 
authorization, some States undoubtedly place otherwise promising 
integration initiatives on the shelf for fear that they invest limited 
resources into constructs or models that could be invalidated in a few 
short years. The elimination of the historic uncertainty surrounding 
continued SNP authorization will improve stakeholder confidence, 
materially reduce the need for contingency planning, and is likely to 
encourage additional State activity and innovation related to Medicare-
Medicaid integration; each of these results will further the ability of 
SNPs to reliably serve Medicare's most vulnerable beneficiaries now and 
in the future.

    Equally important is that the CHRONIC Care Act takes a thoughtful 
and 
forward-looking approach to this significant policy change: the Act 
both establishes future requirements to promote integration and 
provides flexibility to recognize that not all States may take the same 
approach, or move at the same pace, toward full integration of 
regulatory, financial, and delivery system structures between Medicare 
and Medicaid. We believe that both aspects of the Act's SNP 
authorization are important to ensure the continued quality and 
evolution of SNPs, while still providing States and Plans with the 
tools necessary to continue innovating for the benefit of SNP-eligible 
beneficiaries. We urge all members of Congress to support this policy 
as part of the CHRONIC Care Act.
    ii. opportunities to further enhance the delivery of home- and 
                 community-based services through snps
    The provision and coordination of effective, high-quality medical 
care for seniors with multiple chronic conditions is increasingly 
complex and costly. While many beneficiaries with chronic conditions 
may be able to avoid or delay nursing home placement with appropriate 
home- and community-based services and supports (HCBS), coverage of 
these services has historically been limited. Over time, stakeholders 
have increasingly identified the positive outcomes associated with 
appropriate care delivered at home rather than in an institutional 
setting, and we appreciate the committee's shared recognition of this 
premise. Promising programs like the Independence at Home (IAH) 
demonstration evince an important public commitment to pursue the 
potential savings and quality improvements that can be realized through 
the delivery of tailored, team-based primary care to beneficiaries in 
their homes.
                  iii. expanding supplemental benefits
    The clinical practice of medicine is constantly evolving. This is 
true not only because of advances in clinical practice and technology, 
but also because medical science is increasingly recognizing that a 
``one size fits all'' approach to medicine is not the most efficient 
method for delivering effective care. Similarly, our understanding of 
overall health, and how socioeconomic factors contribute to an 
individual's health in both positive and negative ways, continues to 
evolve and change. While clinical practice increasingly incorporates 
tailored or individualized care, the current capacity of our health-
care system to address social determinants of health is somewhat 
limited; this is often true even where an individual's providers, 
advocates, and payers agree about the adverse health effects of a 
patient's barriers to things like food, clothing, transportation, and 
social support. A prerequisite to effectively overcoming these barriers 
for Medicare beneficiaries is the implementation of a financing 
structure that not only makes appropriate services available (some of 
these services are available through community and social service 
agencies today), but that actually makes them accessible for 
beneficiaries, whether through additional administrative coordination 
or through ``linking'' services like transportation and communication. 
Historically, Medicare's flexibility to address these issues has been 
constrained primarily by the program's ``uniformity'' requirement, 
which limits the ability of MA and SNP plans to offer beneficiaries 
tailored support services except where those services are made 
available to all members. Important initiatives like the CMS Value-
Based Insurance Design (VBID) Model are beginning to incorporate more 
benefit flexibility regarding uniformity requirements, but we believe 
that there is still a significant opportunity to advance the concept of 
targeted, non-traditional services and supports for the benefit of a 
broader MA population.

    We applaud the committee's Chronic Care Working Group for formally 
recognizing one such opportunity in its 2015 ``Options Paper,'' and we 
support the adoption of supplemental benefit flexibility as provided by 
section 302 of the CHRONIC Care Act. This provision of the Act offers 
tremendous potential to positively impact not only the lives and 
overall health of chronically ill MA beneficiaries, but also long-term 
expenditures in the MA program, particularly with respect to avoidable 
acute care. The act's approach to expanding allowable supplemental 
benefits for chronically ill MA beneficiaries provides critical 
authority for CMS to establish the details of implementation within 
well-considered statutory guidelines; it will promote a collaborative 
approach between CMS, MA plans, and other stakeholders. The Act's 
implementation date of 2020 provides for an appropriate implementation 
schedule, and it will likely allow implementation to be informed by 
early results from the current VBID Model demonstration. We look 
forward to working with CMS on this important initiative following the 
CHRONIC Care Act's enactment.

    The CHRONIC Care Act's expansion of supplemental benefits is a 
significant step forward for the MA program, and we hope that CMS will 
continue to work with MA plans and stakeholders to provide maximal 
flexibility related to the provision of unique supplemental benefits as 
part of a beneficiary's individualized health-care plan. While a risk-
bearing ACO or MA plan today has financial incentives to efficiently 
and effectively manage a beneficiary's care, current Medicare rules 
create marked gaps in the ability of these entities to address social 
determinants of health that may be significantly contributing to a 
beneficiary's health and care utilization. For example, a beneficiary 
suffering from COPD might repeatedly present to the emergency 
department for breathing difficulty during the summer. After exhausting 
medication and other clinical interventions, the beneficiary's primary 
care team or care manager might reasonably conclude that the most 
effective intervention is in fact a window air conditioning unit. While 
we recognize that this type of purchase is well outside the boundaries 
of traditional Medicare program reimbursement, the use of a risk 
bearing entity's rebate dollars in this scenario would be money well 
spent in support of beneficiary health and a reduction in emergency 
department utilization. We believe that this level of flexibility is 
appropriately balanced with CMS authority to adopt this approach 
exclusively in the future for risk-bearing entities without altering 
the existing MA bid structure, ACO cost methodology, fee-for-
service reimbursement rules, or approved supplemental benefits. This 
approach would allow the agency to collaborate with stakeholders and 
ensure that such flexibility is carefully implemented, subject to 
appropriate measurements of success, and designed in a manner that will 
only reduce, not increase, Medicare program costs.
                        iv. telehealth services
    There is growing recognition among stakeholders that telehealth 
services have the potential to not only add convenience and increase 
patient access to care, but also to improve the overall quality of 
care, reduce delivery system inefficiencies, increase patient adherence 
and engagement, and ultimately reduce long-term costs in the Medicare 
program. Unfortunately, current law (SSA section 1834(m)) narrowly 
limits the types of services for which the Medicare program will 
provide reimbursement. Even in the MA program, plans are 
disincentivized from offering telehealth services because they must 
either be paid for through rebate dollars or incorporated into an 
additional enrollee premium charge. Critical to any consideration of 
telehealth reimbursement in Medicare is the growing recognition of 
telehealth as a service setting or modality rather than a distinct 
service; patients access telehealth services in place of, rather than 
as a supplement to, similar face-to-face care. A 2014 analysis of 
UPMC's e-visit program, Anywhere Care, found no evidence that e-visits 
or other telehealth initiatives were additive to UPMC Health Plan 
members' care costs; in fact, data indicated that members who utilized 
an e-visit had a lower overall cost of care for the conditions treated 
than members who sought the same care in an emergency room, urgent care 
center, primary care office, or retail clinic. While we understand the 
caution with which policymakers have to date viewed changes in law that 
are necessary for broader Medicare coverage of telehealth, we applaud 
the Working Group and the sponsors of the CHRONIC Care Act for 
recognizing the positive impact that telehealth is likely to have for 
Medicare beneficiaries.

    With more than 20 distinct telehealth services available through 
UPMC providers, UPMC has and continues to be an ardent supporter of 
developing and utilizing innovative telehealth and remote monitoring 
technologies. Our current services include tele-primary care, tele-
stroke, tele-dermatology, tele-psychiatry, tele-cardiology, remote 
specialty consultation, and both pre- and post-surgical care, among 
others. The availability of these services allows UPMC to rapidly 
deliver world class specialty care and comprehensive consultations to 
rural patients who may be several hours from the nearest specialty 
practice or clinic, nursing home residents who do not have 24/7 access 
to many types of care, and chronically ill patients living in home- and 
community-based settings for whom physical travel is often costly, 
complicated, and burdensome.

    As an example, consider a medically complex rural nursing home 
resident with CHF and diabetes who is in need of a sophisticated 
gastrointestinal surgical procedure. Without access to telehealth 
services, this patient would likely spend a full day traveling to a 
major metro area for a pre-surgical consultation. Her trip will likely 
be coordinated with those of other residents, all of whom will spend 
hours on highways or in waiting rooms while trying not to significantly 
deviate from the necessary routine of their medication regime or blood 
sugar testing. A month later, she would repeat the process for her 
scheduled surgery. In the following weeks, she would spend at least 
another 2 full days traveling back and forth for follow-up care. This 
scenario is disruptive to the patient, increases the risk of 
complications due to the stress of extended post-surgical travel, and 
includes significant secondary costs for travel and associated patient 
support. By contrast, effective use of pre- and post-surgical 
telehealth services could have limited the patient to a single trip for 
surgery. In this way, telehealth can not only reduce the total cost of 
care, but also makes care like surgical procedures less disruptive, and 
in many ways less stressful, for patients. In addition to post-surgical 
follow-up care, UPMC's remote monitoring program tracks chronically ill 
patients who have been identified as ``high risk'' for inpatient 
readmissions. By example, the system tracks blood oxygen levels and 
blood pressure of patients with congestive heart failure (CHF) to 
facilitate rapid outreach and intervention in the event of any 
concerning clinical data. In 2014, the program reduced 30-day 
readmission rates for participating CHF patients by 7 percent when 
compared to non-participating CHF patients.

    While UPMC and others have successfully implemented a host of 
telehealth services to support patients' physical health, the increased 
patient access associated with telehealth may be even more significant 
for mental and behavioral health issues, which disproportionately 
impact Medicaid-eligible members (and by extension, dual-eligibles) who 
face additional structural and socioeconomic barriers to accessing 
care. UPMC's behavioral health managed care organization, Community 
Care Behavioral Health, recently implemented a pilot program to provide 
telepsychiatry services for Medicaid members in rural Pennsylvania. 
This program resulted in a 25% improvement for 30-day patient 
engagement, and a significant reduction in inpatient readmission rates 
for those patients who were able to access a telepsychiatry resource. 
Given the positive implications for quality and cost savings that we 
have seen through this and other telehealth initiatives, we believe 
that broader, more flexible reimbursement policies for telehealth have 
real promise to improve overall care costs, quality of care, and 
patient satisfaction across a range of both physical and behavioral 
health services.

    We appreciate the Working Group's insightful recognition of 
telehealth's potential in their 2015 Policy Options document, and are 
encouraged by the inclusion of expanded telehealth services for 
Medicare Advantage as provided for by the CHRONIC Care Act. We support 
adoption of the act's telehealth provisions, and we look forward to 
continuing to work with the committee and with CMS to identify 
additional opportunities to employ cost-effective telehealth 
interventions in the future.
                    v. value-based insurance design
    As you are aware, UPMC Health Plan is currently participating in 
the CMS Innovation Center's VBID Model. The nuances of VBID 
implementation may vary among participating plans, but the Model is 
fundamentally designed to leverage cost-
sharing and other plan design elements in order to encourage enrollees' 
use of high-value clinical services. UPMC Health Plan has extensive 
experience implementing value-based and consumer-driven plan designs in 
commercial employer group coverage. Our experience with this approach 
in the commercial insurance market over a number of years has been 
positive, and our data from that experience demonstrates that a 
thoughtful combination of incentives and enrollee engagement efforts 
can be combined to produce meaningful cost savings. We are excited to 
partner with CMS in evaluating the expected positive impact of VBID for 
Medicare beneficiaries, and we look forward to continued collaboration 
as the Model demonstration period continues.

    The VBID Model is currently operating in seven States, with three 
State expansion scheduled for 2018. Section 301 of the CHRONIC Care Act 
would expand the Model to every State by 2020. As stated above, we 
believe that the VBID Model holds significant promise of positive 
results in Medicare. We appreciate that the committee and the act's 
sponsors share our belief in the potential of VBID, and we support the 
act's proposed expansion thereof. During the demonstration period, we 
will collectively have an opportunity to learn from this innovative 
initiative and to modify guidelines based on these findings.
                             vi. conclusion
    We again thank the Senate Finance Committee and the members of the 
Chronic Care Working Group for this opportunity and their consideration 
of their comments. We salute the committee's continued pursuit of 
meaningful, cost-effective solutions designed to improve the Medicare 
program for beneficiaries with chronic conditions. We would be pleased 
to engage in further dialogue on this important topic and to provide 
additional information or data on our foregoing statements to support 
the committee's efforts in this regard. We look forward to continued 
collaboration in the future.

                                 ______
                                 
  Prepared Statement of Stephen Rosenthal, Senior Vice President for 
         Population Health Management, Montefiore Health System
    Thank you, Mr. Chairman and members of the committee.

    My name is Stephen Rosenthal. I am senior vice president for 
population health management of Montefiore Health System and the chief 
operating officer of the Montefiore Accountable Care Organization.

    I appreciate this opportunity to discuss solutions to one of the 
most vexing problems facing the Nation's health system: how to 
effectively and efficiently care for the growing numbers of Americans 
who suffer from chronic conditions. I commend the committee for its 
unrelenting focus on this topic.

    Montefiore Health System is a premier academic health system and 
the University Hospital for Albert Einstein College of Medicine. We 
serve the 3.1 million people living in the New York City region and the 
Hudson Valley, a combination of rural, urban, and suburban communities. 
Approximately 80 percent of the patients discharged from our hospitals 
are enrolled in Medicare, Medicaid, or both programs, or are uninsured. 
The Health System includes 11 inpatient hospitals and more than 200 
outpatient sites, including a rehabilitation hospital, a State of the 
art surgical/specialty center campus ``hospital without beds,'' a 
multi-county ambulatory network, a skilled nursing facility, a school 
of nursing, two home health agencies and New York State's first 
freestanding emergency department. With our new member and affiliate 
locations in Westchester, Rockland, and Orange counties, our regional 
integrated delivery system focuses on delivering patients highly 
specialized clinical expertise close to their home.

    Our model is unique among our colleagues in that we have for many 
years combined nationally recognized clinical excellence with 
accountable, value-based care that is delivered where, when and how 
patients need it most.

    Montefiore has deep roots in treating chronic disease, dating back 
to our founding in 1884 by Jewish philanthropists as a care facility 
for patients with chronic illnesses. Today, we are one of the largest 
health systems in the country, and we have more than 400,000 patients 
in risk arrangements across Medicare, Medicaid, and commercial 
insurance. We take a great deal of pride in the role we play as a 
national leader in the movement toward value-based care, and in sharing 
our journey and learnings with colleagues and policymakers.

    As early as 1995, Montefiore's leadership recognized the need for 
transformational change in a health-care delivery system serving a 
preponderance of government program beneficiaries and formed the 
Montefiore Independent Practice Association (MIPA) to enable it to 
negotiate value-based contracts with health plans. An IPA is similar to 
an ACO. It is an organized group of providers, with its own governing 
body, that come together as an integrated network focused on improving 
the quality of care for individuals and a population while lowering 
costs.

    A year later, CMO, Montefiore Care Management (CMO) was formed to 
provide the infrastructure to manage the care of the patients covered 
by those contracts. Before the term was widely used, we employed a 
population health management approach, focusing on identifying and 
stratifying the at-risk population--primarily those with chronic 
conditions--and engaging them with targeted care management 
interventions.

    More than a year before the passage of the Patient Protection and 
Affordable Care Act, Montefiore's president and CEO, Dr. Steven M. 
Safyer, long an outspoken advocate for accountable care, established a 
high-level planning group in anticipation of Federal, State, and 
private payer opportunities focused on population health management.

    Montefiore was one of 10 organizations that participated in NCQA's 
beta testing of its accountable care organization accreditation 
standards and processes, and we eagerly applied to become a Pioneer 
Model ACO when that initiative was announced by CMS in 2011. The 
Pioneer ACO program, established as part of the Affordable Care Act, 
was a catalyst for the expansion of ACO and risk-based programs. It 
also allowed us to create aggregate-level population health 
interventions for the Medicare fee-for-service population. As one of 
the original 32 Pioneers, we have achieved overall savings for Medicare 
of nearly $70 million out of a total cost of care of more than $2.2 
billion. We are now participating in the Next Generation ACO program 
with 55,000 beneficiaries, and we are optimistic that we will continue 
to achieve savings for Medicare and reinvest our share of those savings 
in our delivery system.

    When we applied to become a Pioneer ACO, Montefiore was a four-
hospital system serving primarily Bronx County, one of the Nation's 
poorest and most disproportionately disease-burdened counties. Today, 
the Montefiore ACO's network includes 13 hospitals and three federally 
qualified health centers and extends to the whole of New York City and 
to Westchester, Rockland, Orange, and Sullivan counties in New York 
State's Hudson Valley, beyond the Montefiore Health System itself, in 
fact. The network comprises more than 3,800 primary care and specialty 
physicians, almost 30% of whom are in private practices in their 
communities.

    Yet it is our decades-long experience providing care for the 1.4 
million residents of the Bronx, 75% of whom receive their health-care 
services through the Medicare and Medicaid programs, that gave us the 
expertise to successfully manage the care of the beneficiaries 
attributed to our ACO.

    In addition to being the Nation's poorest urban county (almost one-
third of its residents live in families with incomes below the Federal 
poverty line), the Bronx is the most disease-burdened county in New 
York State, ranked last among 62 counties on both ``health factors'' 
and ``health outcomes,'' and with highly elevated rates of diabetes and 
chronic cardiac and pulmonary conditions.

    CMO has care management teams with expertise in diabetes, chronic 
kidney disease, cancer, heart disease, asthma, and COPD, and behavioral 
health as well as one team that specialize in helping patients and 
their families with care transitions and one composed of pharmacists 
that assists patients with understanding and adhering to their 
medication regimens. The CMO's quality improvement and provider 
relations staff assist physician practices on quality improvement and 
data reporting and transformation of practices into Patient Centered 
Medical Homes (PCMHs).

    We reach out to our highest risk patients who have multiple chronic 
and acute care problems to conduct comprehensive health assessments 
that cover both medical and behavioral problems and socioeconomic 
challenges including housing, employment, nutrition, and access to 
health care. We identify all of the providers they are seeing to 
develop with them a comprehensive care plan and to help them coordinate 
their care.

    We appreciate that our patients need access to high quality 
providers, who understand their language and culture, are available 
when needed and are willing to coordinate with the other providers our 
patients see. Our patients need information about their conditions, 
help in learning self-management skills and linkages to community and 
government sponsored social service agencies to resolve their 
socioeconomic challenges.

    And that is why we applaud the committee's focus on helping health-
care systems care for their patients with chronic conditions, which are 
difficult to deal with under the best of circumstances and often 
require multiple providers to properly control.

    If you have any doubts about the importance of this concentration--
for the health of the patients as well as the Nation's health system, 
consider this. In our experience, 5% of the 400,000 individuals covered 
by Montefiore's value-based contracts, including the 55,000 Medicare 
beneficiaries currently attributed to our NextGen ACO, account for 65% 
of the total cost of care--and that is largely because of chronic 
conditions.

    As I said, Montefiore has enjoyed success in managing value-based 
contracts, including the ACO model. But we have learned that to be 
continually successful an ACO has to continually evolve and build its 
arsenal of interventions and incentives that promote primary care, and 
adherence to personalized care plans, as well as efficiently use scarce 
financial resources. To that end, I applaud the ACO provisions included 
in the CHRONIC Care Act, some of which build upon provisions included 
in the NextGen ACO program, and offer you our support for them.

    In our experience, prospective attribution is one of, if not the 
most critical component to success in two-sided risk models. While 
retrospective assignment of patients may be appropriate in one-sided 
risk models, in two-sided risk arrangements, prospective attribution 
allows us to quickly identify those beneficiaries with a history of 
high costs and high utilization of services, as well as those whose 
medical records indicate the potential for becoming high cost and high 
utilizers. Without prospective attribution, it is difficult to 
effectively deploy resources to generate savings, because patients that 
the ACO provides care coordination services during the performance 
period may not be attributed to the ACO for a sufficient period of time 
to have an impact on their care, or be attributed to the ACO at the end 
of the year.

    (As an aside, when we send out the notification letter to our newly 
attributed beneficiaries each year, it is not unusual for us to be 
asked by some beneficiaries if their spouse, who did not have the 
claims history with a particular provider to merit attribution, could 
also become part of the ACO so they could benefit from our care 
coordination services.)

    Another component to an ACO's success is increasing patient access 
to services necessary to manage chronic disease. Your proposal to 
expand the ability of ACOs to employ telehealth solutions is an 
estimable way of doing that. To serve our urban population that faced 
challenges getting to office appointments, Montefiore initially focused 
its attention on a home visiting program. But as the evidence has built 
that telehealth technology can be as successful in urban settings as it 
is in rural areas--and as our service area has expanded beyond the high 
rise neighborhoods of the Bronx--we have begun to investigate solutions 
that we believe will be cost effective and contribute to improved 
quality of care, including telehealth and other 
technology-based interventions.

    In fact, we are presenting a paper at a session of the annual 
meeting of the American Psychiatric Association next week that 
describes preliminary results from a pilot of a smartphone behavioral 
care management platform. The data indicate a threefold increase in the 
number of contacts Montefiore's care managers were able to make with 
behavioral health patients and enables them manage caseloads of up to 
120 patients, a significant measure of efficiency given the low-income, 
ethnically diverse population in the pilot. This application does not 
fit the traditional definition of telehealth but it is typical of the 
innovative approach you are looking to advance.

    I urge you to contemplate an expansion of the definition of 
telehealth to include audio-only and all modalities that allow 
communication between providers, care managers and patients in a 
seamless fashion, especially in low-income communities that may not 
have access to videoconferencing technology. The potential for 
technology to improve patient engagement and care is not only 
applicable to chronic care, but to the vulnerable elderly as well.

    Finally, I am intrigued by your proposal to ACOs to offer 
beneficiaries incentives to obtain primary care services from its 
network providers. We--and I suspect, most other ACOs--already offer 
incentives to our providers for meeting both quality and cost metrics. 
Why not allow us to offer similar incentives to their patients? While 
there may be a cost to developing the infrastructure to administer the 
benefit, it seems to me to have the potential to be a win-win-win-win 
proposition. It could benefit the patient directly, both financially 
and in terms of improved health; the provider, by improving his or her 
quality scores; the ACO itself by increasing its potential for shared 
savings; and the Medicare program by lowering the total cost of care to 
the system. Such an incentive may be especially effective in a low-
income, price-sensitive population like the one we serve. We know that 
patient outcomes are significantly improved if they access their 
providers regularly and when needed. Providing an incentive to promote 
compliance is likely to encourage that.

    Research demonstrates, and our actual experience shows, that 
patients who regularly fail to keep scheduled appointments with their 
physicians or other providers are at higher risk for complications and 
deterioration of their health status. While it is difficult to track 
with exactitude, the no-show rate among the population that Montefiore 
has care management responsibilities for is in the neighborhood of 20%, 
a rate that potentially endangers the health of the individuals and our 
ability to meet quality metrics and cost saving targets associated with 
the value-based contracts covering them.

    An added benefit to an incentive is the potential to encourage 
patients in the fee-for-service program to stay within the ACO network, 
without limiting their choice in anyway. Keeping patients within the 
network is a fundamental challenge for ACOs in a fee-for-service 
environment, and you have proposed an innovative solution to this 
issue.

    It is exactly that kind of creative thinking that has led 
Montefiore to continually evaluate and modify its approach to 
population health. The result for us has been an increased focus on the 
socioeconomic determinants of health; partnerships with government 
agencies, community organizations and businesses to provide the full 
range of services our patients require; and special arrangements with 
providers such as skilled nursing facilities to ensure that our 
patients are ensured the highest quality, most cost-effective care 
across the continuum of care.

    On behalf of the Montefiore ACO and the entire Montefiore Health 
System, I thank you for your efforts to advance accountable care with 
proposals that I believe have the potential to improve quality and 
lower costs. I look forward to working with you to achieve our shared 
goal of a better health system for all Americans.

    Thank you. I will be happy to answer any questions you have.

                                 ______
                                 
   Prepared Statement of Lee Schwamm, M.D., Professor of Neurology, 
Harvard Medical School; Executive Vice Chairman of Neurology, Chief of 
 the Stroke Division, and Director of the Partners TeleStroke Network, 
    Massachusetts General Hospital; on Behalf of the American Heart 
                Association/American Stroke Association
    Chairman Hatch, Ranking Member Wyden, and other members of the 
committee, thank you for the opportunity to testify on behalf of the 
American Heart Association/American Stroke Association at today's 
hearing about the CHRONIC Care Act (Creating High-Quality Results and 
Outcomes Necessary to Improve Chronic Care Act, S. 870). I commend you 
for your bipartisan work to strengthen and improve health outcomes for 
Medicare beneficiaries living with chronic conditions. Your 
legislation, if enacted, would help patients receive care that meets 
their unique chronic health-care needs, as well as create incentives 
for the provision of coordinated care services to high-cost Medicare 
beneficiaries. This represents an important step forward in moving the 
Medicare program away from a system based on episodic care to a more 
responsive and comprehensive health care program. The American Heart 
Association is pleased to offer our support for this legislation.

    We recognize that implementing policies that facilitate increased 
care coordination, incentivize high quality care, and increase the 
Medicare program's efficiency while improving health-care outcomes and 
reducing costs is a considerable challenge with no single policy 
solution. We applaud the committee for including several provisions in 
this legislation that take significant steps forward to improving care 
coordination for individuals with cardiovascular disease and stroke. We 
support policies that would allow Medicare Advantage (MA) plans to use 
additional, clinically appropriate telehealth technologies. We also 
support proposals that would give MA Plans more flexibility to vary 
benefit structures based on chronic conditions and offer a wider array 
of supplemental benefits than they currently do. In addition, we 
support the request for studies by the Government Accountability Office 
on medication synchronization and obesity drugs. These and other 
provisions in the bill will be extremely beneficial to individuals 
suffering from cardiovascular disease and stroke.

    However, we are particularly grateful that Congress included a 
provision that would expand the use of telehealth for individuals with 
stroke. In addition to being a long-time volunteer of the American 
Heart Association, I am also a member of the American Academy of 
Neurology. The American Heart Association/American Stroke Association 
has been working very closely with the AAN to improve Medicare's 
coverage of stroke telemedicine--or ``telestroke'' care, as it is now 
commonly called. We applaud the Finance Committee for including this 
common-sense provision in the CHRONIC Care Act.

    Stroke takes an enormous toll on families and on our Nation. It is 
our Nation's No. 5 killer and a leading cause of serious, long-term 
disability and dementia.\1\ As the Baby Boomers age, it is critically 
important that we reduce the burden of this devastating disease on 
stroke survivors, their families and on Federal health-care programs. 
According to MedPAC, stroke is the leading Medicare diagnosis for 
inpatient rehabilitation stays,\2\ and a leading diagnosis requiring 
nursing home care. A report released by the American Heart Association 
earlier this year projects that this burden is only going to increase: 
despite better prevention, the number of people living with stroke will 
increase from 7.5 million Americans in 2015, to 11.2 million in 2035, a 
50 percent increase over the next 20 years. The study also estimates 
that the medical costs of stroke in the U.S. will more than double, 
from $37 billion in 2015, to $94 billion in 2035.\3\ By improving 
access to telestroke care, we can ease this burden.
---------------------------------------------------------------------------
    \1\ Benjamin, E.J., et al. ``Heart disease and stroke statistics--
2017 update: a report from the American Heart Association,'' 
Circulation, 2017;135:e1-e458.
    \2\ Medicare Payment Advisory Commission. ``March 2016 Report to 
the Congress: Medicare Payment Policy,'' March 15, 2016. Accessed 
online at: http://www.medpac.gov/-documents-/reports.
    \3\ American Heart Association/American Stroke Association. 
Cardiovascular Disease--A Costly Burden for America: Projections 
through 2035, February 14, 2017. Accessed online at: http://
www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/
ucm_491543.
pdf.
---------------------------------------------------------------------------
                             time is brain
    In the treatment of stroke, we often say that ``time is brain.'' 
For every minute that a stroke goes untreated, 2 million brain cells 
and 14 billion connections between them die, and they don't grow back. 
The clot-dissolving drug Alteplase (or tPA) and mechanical clot-removal 
devices are highly effective treatments for the most common type of 
stroke--acute ischemic stroke--and significantly reduce disability from 
stroke by restoring blood flow to the affected areas of the brain, but 
they must be administered as quickly as possible after stroke symptoms 
start. Research from the American Stroke Association's Target: Stroke 
initiative shows definitively that stroke patients who get treated with 
tPA within 60 minutes of hospital arrival do significantly better than 
those treated more slowly. In particular, we have found that for every 
15 minute reduction in treatment time, 5.1 percent more patients 
recover so completely that they can return directly home from the 
hospital.\4\ Ischemic stroke patients who are treated with the clot-
busting drug within 90 minutes of symptoms starting are nearly three 
times more likely to recover with little or no disability.\5\ 
Similarly, more than 90 percent of patients treated with a clot 
retrieval device within 150 minutes of stroke onset recover with little 
or no disability.\6\
---------------------------------------------------------------------------
    \4\ Fonarow, G.C., Zhao, X., Smith, E.E., et al. ``Door-to-needle 
times for tissue plasminogen activator administration and clinical 
outcomes in acute ischemic stroke before and after a quality 
improvement initiative,'' JAMA, 2014;311:1632-1640.
    \5\ Marler, J.R., et al. Neurology, 2000;55(11)1649-55.
    \6\ Goyal, M., et al. Radiology, 2016;270(3):888-97.

    I have seen firsthand the miraculous difference these treatments 
can make for patients, but unfortunately, only about 3.4 to 5.2 percent 
of patients receive the clot-busting medication \7\ and even fewer 
patients are treated with clot retrievers. Among Medicare-eligible 
patient discharges, the national average tPA treatment rate is only 2.4 
percent.\8\ There are a number of reasons why treatment rates have 
remained so low, including long distances to stroke center hospitals, a 
shortage of vascular neurologists, and patients not arriving at the 
hospital within the treatment time window.\9\ The good news, however, 
is that the use of telestroke has proven to be extremely effective in 
increasing the percentage of stroke patients who receive Alteplase and 
in reducing the time it takes to get the treatment started.
---------------------------------------------------------------------------
    \7\ Adeoye, O., et al. ``Recombinant tissue-type plasminogen 
activator use for ischemic stroke in the United States: a doubling of 
treatment rates over the course of 5 years,'' Stroke, 2011;
42:1952-1955.
    \8\ Kleindorfer, D.O., Yingying, X., et al. ``U.S. Geographic 
Distribution of rt-PA Utilization by Hospital for Acute Ischemic 
Stroke,'' Stroke, 2009;40:3580-3584.
    \9\ Schwamm, L.H., et al. ``Recommendations for the implementation 
of telemedicine within stroke systems of care: A policy statement from 
the American Heart Association,'' Stroke, 2009;40:2635-2660.
---------------------------------------------------------------------------
                        telestroke is effective
    Rapid and accurate diagnosis of acute ischemic stroke is a critical 
first step to ensuring that these patients receive the optimal care. A 
variety of conditions can mimic acute stroke, but many rural hospitals 
and even suburban community or inner-city hospitals do not have stroke 
neurologists available in house or on-call around-the-clock to examine 
and diagnose patients in-person. Even in urban or suburban settings, 
where approximately 94 percent of strokes occur, patients may 
experience delays to diagnosis and treatment. To a large extent this is 
because there is a shortage of vascular neurologists, many hospitals do 
not have any, and in those that do neurologists having competing 
demands on their time that prevent them from being in the Emergency 
Department 24/7 in person. Telemedicine can meet this need. We estimate 
from 2014 data that the number of Medicare beneficiaries 65 and older 
who have a stroke and would be newly eligible for a telestroke 
consultation to be approximately 522,000. This would include 
individuals in rural areas that do not meet the current and fairly 
narrow definition of ``rural'' for Medicare payment of telestroke 
services.

    When a patient presents at a hospital that does not have a stroke 
expert readily available, the Emergency Department physician can use a 
telemedicine network to immediately consult with a stroke expert. Using 
fully interactive and secure audio-video systems, the stroke expert can 
interact with the patient and the bedside physician and swiftly and 
accurately obtain the proper history, perform the NIH Stroke Scale, (a 
brief stroke severity scale), review the CAT scan and confirm the 
diagnosis of stroke. The interpretation of the brain imaging is 
critical to ensure that the patient is not having a hemorrhagic stroke 
or other diagnosis that would make use of tPA unsafe.

    This use of telemedicine in the acute treatment of stroke has 
greatly improved the percentage of patients who receive the recommended 
acute stroke treatment, as numerous studies have demonstrated. One 
recent study of four urban hospitals in Illinois with low tPA treatment 
rates found that their utilization of tPA increased by two to six times 
after telestroke was implemented.\10\ Moreover, the outcomes for stroke 
patients who are cared for in hospitals with telemedicine support have 
been comparable to those achieved in other stroke centers and have 
surpassed those achieved by general hospitals without telemedicine 
support or stroke units.\11\
---------------------------------------------------------------------------
    \10\ Cutting, S., et al. ``Telestroke in an urban setting,'' 
Telemed. J. E.-Health, 2014;20(9):
855-7.
    \11\ Schwamm, L.H., Holloway, R.G., Amarenco, P., Audebert, H.J., 
Bakas, T., Chumbler, N.R., et al. ``A review of the evidence for the 
use of telemedicine within stroke systems of care: a scientific 
statement from the American Heart Association/American Stroke 
Association,'' Stroke, 2009;40:2616-2634.

    Despite the proven benefits of telestroke, Medicare's coverage of 
it is woefully outdated. The current Medicare policy of limiting 
coverage for telehealth services to those patients originating in only 
rural areas has hampered the development of sufficient telestroke 
coverage. The most significant step Congress could take would be to 
allow Medicare to reimburse for telestroke evaluations for patients 
regardless of their location, as the CHRONIC Care Act would do.
                         telestroke saves money
    In addition to improving access to the recommended care, we believe 
that greater use of telestroke will also result in health care cost 
savings by reducing chronic disability and the need for more extensive 
and ongoing medical care. Several studies have clearly shown that the 
use of tPA is cost-saving for stroke care. According to a study 
published in the New England Journal of Medicine, stroke patients 
receiving clot-busting therapy were at least 30 percent more likely to 
have minimal or no disability at 3 months, compared to patients who did 
not receive this treatment. These patients also have shorter hospital 
stays and are more frequently discharged to their homes rather than to 
more costly nursing homes.\12\ Another study found that the average 
cost savings when administering tPA was $4,255.00 in 1996 dollars per 
treated patient, largely as a result of decreased utilization of 
nursing home and rehabilitation care by the patient.\13\ Yet another 
study aimed at evaluating the cost utility of telestroke networks 
estimated net savings of $1,436 per patient, even after accounting for 
the costs of implementing the telestroke network and administering 
tPA.\14\
---------------------------------------------------------------------------
    \12\ The National Institute of Neurological Disorders and Stroke 
rt-PA Stroke Study Group. ``Tissue plasminogen activator for acute 
ischemic stroke,'' N. Engl. J. Med., 1995;333:1581-1587.
    \13\ Fagan, S.C., Morgenstern, L.B., Petitta, A., Ward, R.E., et 
al. ``Cost-effectiveness of tissue plasminogen activator for acute 
ischemic stroke,'' Neurology, 1998;50:883-890.
    \14\ Demaerschalk, B.M., Switzer, J.A., Xie, J., Fan, L., Villa, 
K.F., and Wu, E.Q., ``Cost utility of hub-and-spoke telestroke networks 
from societal perspective,'' Am. J. Manag. Care, 2013;19:976-85.

    In fact, the American Heart Association has estimated that the 
Medicare and Medicaid programs could save as much as $1.2 billion over 
10 years, even after the costs of providing more telestroke evaluations 
and more tPA treatments are factored in. I understand that the 
Congressional Budget Office may not allocate the full amount of savings 
to the Federal Medicare and Medicaid programs since some of the savings 
that results from reducing the need for nursing home care accrues to 
State rather than Federal Governments and to patients and their 
families. I would argue, however, that even if the Federal Government's 
savings from Medicare and its share of Medicaid savings is more modest 
or takes time to be realized, taking this step to improve the quality 
of stroke care is still highly cost-effective and is the right thing to 
---------------------------------------------------------------------------
do for patients.

    I believe this change in Medicare law is long overdue, and I am 
heartened by the growing number of lawmakers and organizations that 
have endorsed telestroke care. I want to thank Senators John Thune, 
Brian Schatz, and Roger Wicker for also introducing stand-alone 
legislation to expand Medicare's coverage for telestroke evaluations. 
Companion legislation in the House achieved 171 bipartisan cosponsors 
in the last Congress and is well on its way to exceeding that number 
this year with 77 co-sponsors already. In addition, organizations such 
as AARP, the American Hospital Association, the American Medical 
Association, and the National Coalition for Health Care have also 
expressed their support for lifting Medicare's restrictions on 
telestroke coverage. Finally, the Medicare Payment Advisory Commission, 
in its June 2016 report to Congress, found telestroke to be one of the 
most beneficial and cost-effective applications of telehealth and 
suggested that policymakers may want to expand Medicare coverage of 
telestroke to urban settings,\15\ as the CHRONIC Care Act would do.
---------------------------------------------------------------------------
    \15\ Medicare Payment Advisory Commission. June 2016 Report to the 
Congress: Medicare and the Health Care Delivery System. June 15, 2016. 
Accessed online at: http://www.medpac.gov/-documents-/reports.

    In conclusion, telestroke is supported by a wealth of evidence and 
is a common-sense, cost-effective step that the committee can take to 
reduce the burden of stroke as a chronic disease. I am convinced that 
expanding the use of telestroke will greatly improve the quality of 
care that stroke patients receive, increase the utilization of 
effective acute stroke treatments, reduce stroke-related disability for 
many Americans, and save the health-care system money. These win-win 
opportunities are rare in health care, and I urge the Senate Finance 
Committee to act quickly on the CHRONIC Care Act and to send it to the 
full Senate and then the House for approval. Thank you again for 
addressing the challenging issues related to caring for Medicare 
patients with multiple chronic conditions. We greatly appreciate the 
thought and deliberations that went into the development of this bill 
and for the opportunity to express our strong support at today's 
---------------------------------------------------------------------------
hearing.

                                 ______
                                 
                 Prepared Statement of Hon. Ron Wyden, 
                       a U.S. Senator From Oregon
    Thank you, Chairman Hatch. I have looked forward to this morning 
for many years. That's because the Finance Committee is beginning to 
tackle to the premier challenge of American health-care policy--
specifically, by updating the guarantee of Medicare to better serve 
seniors with chronic illness.

    When I was director of the Oregon Gray Panthers, Medicare had two 
parts--A and B. If you broke your ankle and had surgery in the 
hospital, you used Part A. If you got a bad case of the flu, and you 
saw the doctor in the office, you used Part B.

    That is not Medicare today. Today, Medicare is about cancer, 
diabetes, heart disease, strokes, and other chronic conditions. Seniors 
who have two or more of these chronic conditions account for more than 
90 percent of Medicare spending. And today, seniors get their care in a 
variety of different ways. There's still fee-for-
service, but there is also Medicare Advantage, Accountable Care 
Organizations, and other innovations being tested today.

    Because Medicare is a guarantee of defined benefits, it's past time 
to update this promise so as to deliver to patients with chronic 
conditions the best possible care in the most efficient manner. The 
legislation we will discuss today begins this transformations: more 
care at home and less in institutions. Expanded use of life-saving 
technology. A stronger focus on primary care. In my view, still to 
come, is ensuring that each senior with multiple chronic conditions has 
an advocate to guide them through what can be a teeth-gnashing 
experience of navigating American health care.

    I'd like to make two final points. First is to contrast this with 
the partisan handling of the debate over the future of the Affordable 
Care Act. In this instance, the doors were open, not closed. There has 
been bipartisan cooperation, not partisan reconciliation. And the 
public was asked to help improve the bill, rather than being taken for 
granted.

    Finally, I'd like to thank my colleagues, especially Chairman Hatch 
and Senators Isakson and Warner. We'll hear later this morning about 
how this process has been a model for bipartisanship and regular order, 
and it's been an honor to be a part of that process.

    I look forward to hearing from our witnesses.

                                 ______
                                 

                             Communications

                              ----------                              


                       Alliance for Home Dialysis

                      1341 G Street, NW, 6th Floor

                          Washington, DC 20005

Chairman Hatch. Ranking Member Wyden, and members of the Finance 
Committee, on behalf of the Alliance for Home Dialysis (Alliance), we 
are pleased to support the Creating High-Quality Results and Outcomes 
Necessary to Improve Chronic (CHRONIC) Care Act of 2017, which seeks to 
improve the care and treatment of Medicare beneficiaries with multiple 
chronic conditions.
---------------------------------------------------------------------------
    \1\ United States Renal Data System (USRDS), 2015 Annual Data 
Report: Epidemiology of Kidney Disease in the United States.
    \2\ Government Accountability Office, ``Medicare Payment 
Refinements Could Promote Increased Use of Home Dialysis,'' published 
November 16, 2015. Available at http://www.gao.gov/products/GAO-16-125.

The Alliance represents patients, clinicians, providers, and industry 
working to promote policies that facilitate treatment choice for 
individuals in need of dialysis, and to address systemic barriers that 
limit access to the many benefits of home dialysis. These issues are 
particularly important given the nearly half million Americans who are 
currently living with End Stage Renal Disease (ESRD) and depend on 
dialysis for survival.
---------------------------------------------------------------------------
    \3\ Weinhandl, E.D., Liu, J., Gilbertson, D.T., Arneson, T.J., and 
Collins, A.J.: ``Survival in daily home hemodialysis and matched 
thrice-weekly in-center hemodialysis patients.'' J. Am. Soc. Nephrol. 
JASN 23: 895-904, 2012.
    \4\ Weindhandl, E.D., Nieman, K.M., Gilbertson, D.T., and Collins, 
A.J.: ``Hospitalization in daily home hemodialysis and matched thrice-
weekly in-center hemodialysis patients.'' Am. J. Kidney Dis., Natl. 
Kidney Found. 65: 98-108, 2015.

Home dialysis--peritoneal dialysis (PD) and home hemodialysis (HHD)--is 
an important treatment option that offers patients significant quality 
of life advantages, including clinically meaningful improvements in 
physical and mental health. Currently, 10.2 percent of incident 
dialysis patients and 11.5 percent of prevalent dialysis patients 
receive treatment at home.\1\ However, a recent report by the 
Government Accountability Office found that home dialysis could be 
clinically appropriate for at least half of ESRD patients.\2\ Patients 
who choose home dialysis have shown improved clinical outcomes, 
including reduced cardiovascular death and hospitalization 
\3\, \4\ lower blood pressure,\5\ reduced use of 
antihypertensive agents,\6\ and reduced serum phosphorus.\7\ Studies 
have also shown that patients have better mental health outcomes, 
including social function, which is vitally important for overall well-
being.\8\ The Alliance believes that more patients than are currently 
receiving home dialysis are suitable for, and could benefit from, home 
dialysis.
---------------------------------------------------------------------------
    \5\ Kotanko, P., Garg, A.X., Depner, T., et al. ``Effects of 
frequent hemodialysis on blood pressure: Results from the randomized 
frequent hemodialysis network trials.'' Hemodial. Int., Int. Symp. Home 
Hemodial. 19: 386-401, 2015.
    \6\ Jaber, B.L., Collins, A.J., Finkelstein, F.O., Glickman, J.D., 
Hull, A.R., Kraus, M.A., McCarthy, J., Miller, B.W., and Spry, L.A.: 
FREEDOM Study Group, ``Daily hemodialysis (DHD) reduces the need for 
anti-hypertensive medications'' [Abstract]. J. Am. Soc. Nephrol. 20: 
SA-P02461, 2009.
    \7\ FHN Trial Group, et al.: ``In-center hemodialysis six times per 
week versus three times per week.'' N. Engl. J. Med., 363: 2287-2300, 
2010.
    \8\ Finkelstein, F.O., Schiller, B., Daoui, R., et al.: ``At-home 
short daily hemodialysis improves the long-term health-related quality 
of life.'' Kidney Int. 82: 561-569, 2012.

The CHRONIC Act would expand access to quality care in the home by 
authorizing home dialysis patients' clinical assessments via 
telehealth. Providing access to physicians and practitioners through 
telehealth may encourage more patients to adopt home dialysis as a 
treatment option. In addition, with this change, patients currently on 
home dialysis would no longer have to travel as frequently to a 
hospital or facility-qualifying site to interface with an approved 
practitioner, which can increase quality of life and facilitate 
---------------------------------------------------------------------------
employment options.

As the Committee looks to further expand and improve access to quality 
care in the home for ESRD patients, we encourage the examination of the 
scope of telehealth services under the law. The Alliance supports 
permitting patients and their physicians the option to participate in 
telehealth encounters that include not only video interaction, but also 
the transmission of clinical data through technologies like remote 
patient monitoring.

The Alliance appreciates and agrees with the testimony and work Senator 
Wicker and Senator Schatz have done on the CONNECT Act. Senator Wicker 
testified. ``Imagine the incredible impact that this technology could 
have if Medicare would allow its most vulnerable beneficiaries to use 
something like remote patient monitoring. I am confident that the 
success we have seen in Mississippi can be replicated for patients 
across the United States upon enactment of the CHRONIC Care Act and 
ultimately enactment of CONNECT for Health.'' We could not agree more.

The CHRONIC Act will make a meaningful difference for patients with 
ESRD, and we thank you for the significant effort that went into this 
legislative accomplishment. We look forward to continuing to work with 
you to further this work. If you have any questions, please contact 
Michael Spira at michael@homedialysisalliance.
org or 202-466-8700.

Participating Organizations (2017)
American Association of Kidney Patients
American Nephrology Nurses Association
American Society of Nephrology
American Society of Pediatric Nephrology
Baxter
Cleveland Clinic
DaVita
DEKA Research and Development
Dialysis Clinic, Inc.
Dialysis Patient Citizens
Fresenius Medical Care
Greenfield Health Systems
Home Dialyzors United
International Society for Peritoneal Dialysis, North American Chapter
Medical Education Institute
National Kidney Foundation
Northwest Kidney Centers
NxStage Medical
Outset Medical, LLC
Renal Physicians Association
Satellite Healthcare
Southwest Kidney Institute
The Rogosin Institute
TNT Moborg International Ltd.

                                 ______
                                 
                  American College of Physicians (ACP)

                 25 Massachusetts Avenue, NW, Suite 700

                       Washington, DC 20001-7401

                       202-261-4500, 800-338-2746

                       https://www.acponline.org/

                     190 N. Independence Mall West

                      Philadelphia, PA 19106-1572

                       215-351-2400, 800-523-1546

The American College of Physicians (ACP) applauds Chairman Hatch and 
Ranking Member Wyden for holding this hearing concerning Medicare 
policies that will improve care for patients with chronic conditions. 
The College appreciates the sustained commitment of the Senate Finance 
Committee to address reforms that would provide physicians and patients 
with additional tools needed to treat chronic illness.

ACP is the largest medical specialty organization and the second 
largest physician group in the United States. ACP members include 
148,000 internal medicine physicians (internists), related 
subspecialists, and medical students. Internal medicine physicians are 
specialists who apply scientific knowledge and clinical expertise to 
the diagnosis, treatment, and compassionate care of adults across the 
spectrum from health to complex illness.

Two years ago, the Chairman and Ranking Member of this Committee 
established a bipartisan chronic care working group led by Senators 
Johnny Isakson and Mark Warner to analyze current law, discuss 
alternative policy options, and develop bipartisan legislation that 
would be presented to the full Finance Committee for consideration. The 
Chronic Care Working Group has accomplished this goal with the release 
of a bipartisan policy options document and subsequently the 
introduction of bipartisan legislation, the Creating High Quality 
Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act. 
We also commend the Committee for the process that it developed for the 
consideration of chronic care legislation as it was receptive to the 
input of stakeholders, including ACP, as we provided the Committee with 
our expertise and the real world experience of our internists who treat 
individuals with chronic conditions on a daily basis

S. 870, The Creating High-Quality Results and Outcomes Necessary to 
Improve Chronic (CHRONIC) Care Act

ACP was pleased to offer a letter of support, along with our 
recommendations for improvement, for S. 870, The Creating High-Quality 
Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act 
that was introduced in the Senate earlier this year. This bipartisan 
legislation sponsored by the Chairman and Ranking Member of the Finance 
Committee along with members of the Chronic Care Working Group, would 
implement a broad array of reforms to Medicare to provide physicians 
with additional flexibility and resources to treat patients with 
chronic conditions.

Many of the sections of the CHRONIC Care Act were consistent with ACP's 
recommendations to the Committee on policies to include in this 
legislation. The specific sections of the legislation that we support 
are listed below:

ACP Supports the Following Sections of S. 870, as Introduced

      Section 101--Extending the Independence at Home Model of Care

       The Independence at Home Model of Care is a demonstration 
project under Medicare to test a payment incentive and service delivery 
model that uses physician and nurse practitioner-directed home-based 
primary care teams for Medicare beneficiaries with multiple chronic 
illness. This section would extend this demonstration for an additional 
2 years. ACP is supportive of this model of care and supports expanding 
this demonstration project if results continue to be positive.

      Section 303--Increasing Convenience for Medicare Advantage 
Enrollees Through Telehealth

       This section would allow a Medicare Advantage plan to offer 
additional, clinically appropriate, telehealth benefits in its annual 
bid amount beyond the services that currently receive payment under 
Part B. ACP is supportive of this policy as it would expand the role of 
telemedicine as a method of health-care delivery that may enhance 
patient care.

      Section 305--Expanding Use of Telehealth for Individuals With 
Stroke

       This section would expand the ability of Medicare beneficiaries 
presenting with stroke symptoms to receive a timely consultation via 
telehealth to determine the best course of treatment, beginning in 
2018. ACP is supportive of this policy as we support lifting the 
geographic restriction for the purposes of identifying and diagnosing 
strokes through telehealth.

      Section 401--Providing Flexibility for Beneficiaries to Be Part 
of an Accountable Care Organization

       This section would give Accountable Care Organizations (ACOs) in 
the Medicare Shared Savings Plan the choice to have their beneficiaries 
assigned prospectively at the beginning of a performance year. ACP is 
supportive of this section as we encourage giving ACOs the choice to 
have retrospective or prospective assignment of beneficiaries and 
allowing beneficiaries to voluntarily align with their main doctor for 
ACO assignment.

ACP Recommendations for Improvement

We would also like to provide our recommendations for two additional 
sections that we respectfully request that you add to the bill that 
will improve care management codes for individuals with chronic 
conditions and encourage the use of chronic care management services.

     Improving Care Management Codes for Individuals with Multiple 
Chronic Conditions

        This legislation does not address the issue of new chronic care 
        management codes, as was initially referenced in the Chronic 
        Care Working Group Options Document. While we acknowledge this 
        was likely due to the fact that CMS did address it in the FY 
        2017 Final Rule on the Physician Fee Schedule, we believe this 
        warrants attention by the committee within legislation because 
        there is a 40 minute time gap for chronic care management 
        services not recognized by the existing CCM codes in the final 
        rule.

        As you are aware, the 2017 Medicare Physician Fee Schedule 
        Final rule established a new Complex Chronic Care Management 
        code for doctors that provide Complex Chronic Care Management 
        services to patients that last at least 60 minutes in length 
        and for each additional 30 minutes thereafter, which ACP 
        supports. CMS currently provides a code for Chronic Care 
        Management services that last at least 20 minutes but has 
        failed to initiate any new codes for these services that last 
        between 20-40 and 40-60 minutes. ACP remains concerned that the 
        fee schedule fails to adequately value chronic care services 
        between 20-60 minutes, which could lead to more barriers to 
        care for chronic care patients.

    ACP Recommendation

        We urge the Committee to include a section on Improving Care 
        Management for Individuals with Multiple Chronic Conditions 
        that would require CMS to establish two new codes (perhaps 
        initially as G codes) that would recognize the value of care 
        for clinicians who treat patients with chronic care conditions 
        between 20-40 minutes and 40-60 minutes.

    Encouraging Beneficiary Use of Chronic Care Management Services

        ACP is disappointed that this legislation does not address the 
        issue of beneficiary cost sharing, as was initially referenced 
        in the Chronic Care Working Group Options Document. This 
        proposed policy would waive the beneficiary co-payment 
        associated with the current chronic care management code as 
        well as the complex chronic care management code that was 
        recently approved by CMS. We believe waiving this beneficiary 
        co-payment is critical in the effort to improve care to 
        individuals with chronic conditions and it would require a 
        legislative remedy to do it, as explained by CMS.

        Waiving beneficiary cost-sharing, both the co-insurance and 
        deductible, will incentivize beneficiaries to receive these CCM 
        services. Currently, physicians are required to get 
        authorization from patients to initiate CCM services--this is a 
        means of ensuring that these patients are aware of these 
        services and remain engaged partners. As a part of the 
        discussion around this authorization, physicians notify 
        patients that they will be responsible for the co-payment 
        amount associated with CCM. At the time of this discussion, the 
        physician is likely unaware of any supplemental coverage that 
        the patient may have so they must inform the patient that he or 
        she may be required to pay the copayment amount. If the 
        discussion of a co-payment were no longer required because of 
        the elimination of beneficiary cost-sharing, physicians would 
        be more likely to have the discussion with beneficiaries about 
        providing the CCM services that the patient needs. Further, 
        waiving cost-sharing would eliminate any unintended 
        discriminatory impact on beneficiaries of modest means, who 
        more likely will not have any supplemental coverage.

    ACP Recommendation

        We urge the Committee to include a section that would move 
        chronic care management services to the preventive services 
        category under Medicare FFS to eliminate any beneficiary cost 
        sharing associated with these services. Alternatively, you 
        could insert a provision in this bill that would allow CMS to 
        give physicians the option of routinely waiving the copay for 
        chronic care management codes for patients with chronic 
        conditions.

We are pleased that this legislation has been marked-up and approved by 
the Senate Finance Committee with a unanimous vote, and urge Senators 
to include our suggested recommendations as this bill moves toward 
consideration in the Senate. We appreciate the sustained commitment of 
the Chronic Care Working group to improve the health of our patients 
with chronic conditions.

ACP Supports S. 1016, The CONNECT for Health Act

ACP is pleased that the Committee has recognized the expansion of 
telehealth services in Medicare as an additional tool to improve the 
health of patients with chronic conditions. We recently submitted a 
letter of support for S. 1016, The CONNECT for Health Act, that would 
substantially expand the use of telemedicine and remote patient 
monitoring (RPM) services by physicians and other clinicians to improve 
care of patients enrolled in Medicare. We support the expanded role of 
telemedicine as a method of health-care delivery that will improve the 
health of patients with chronic conditions by enhancing patient-
physician collaborations, increasing access to care and members of a 
patient's health-care team, and reducing medical costs when used as a 
component of a patient's longitudinal care.

The CONNECT for Health Act implements reforms to Medicare to improve 
the services offered to patients with chronic conditions by:

      Giving Accountable Care Organizations (ACOs) in the Medicare 
Shared Savings Program (MSSP) with two-sided risk the ability to 
furnish telemedicine and RPM services to their Medicare patients not 
subject to geographic restrictions and originating site requirements 
under current law. ACP would prefer broadening this to allow all MSSP 
tracks (including those ACOs with one-sided risk) to remove those 
restrictions to expand the use of telehealth services.

      Allowing Medicare Advantage plan to offer additional, clinically 
appropriate, telehealth benefits in its annual bid amount beyond the 
services that currently receive payment under Part B. ACP is pleased 
that this provision is consistent a section in the CHRONIC Care Act 
that would implement this policy.

      Requiring that Medicare cover the use of RPM services by 
Medicare providers for certain Medicare beneficiaries with chronic 
conditions. ACP believes that the use of RPM services for patients with 
chronic conditions could help control and manage those conditions and 
improve the health outcomes for those patients while lowering costs.

      Lifting geographic-site restrictions for telestroke evaluation 
and management sites where the Medicare beneficiary is located. ACP 
believes that expanding the use of telemedicine for Medicare stroke is 
an area where evidence supports cost-effectiveness, safety, and 
positive health outcomes associated with telemedicine. Additionally ACP 
has previously supported stroke telehealth-services in the CHRONIC Care 
Act.

We are grateful that the sponsors of the CONNECT for Health Act, 
Senators Brian Schatz (D-HI) and Roger Wicker (R-MS) offered their 
testimony on the role that this legislation would serve in improving 
the health of seniors with chronic conditions at the recent Finance 
Committee hearing regarding bipartisan policy options to improve 
chronic care. We look forward to working with the Committee to 
implement these reforms in Medicare and help our physicians transform 
their practices to expand on the use of telehealth services to improve 
the care provided to patients with chronic conditions.

Conclusion

We appreciate the steadfast commitment of the Finance Committee to 
address the urgent need to reform Medicare to improve the care of 
individuals with multiple chronic conditions. We respectfully urge 
Congress to incorporate our suggested reforms to the Chronic Care Act 
by requiring CMS to establish two new codes to improve the value of 
care for physicians who treat patients with multiple chronic conditions 
and eliminating the beneficiary co-payment associated with the chronic 
care management code. We look forward to working with the Senate to 
improve and advance legislation to improve the health of seniors with 
chronic conditions and welcome this opportunity to provide our views on 
this issue.

                                 ______
                                 
                      Center for Medicare Advocacy

                1025 Connecticut Avenue, N.W., Suite 709

                          Washington, DC 20036

                    http://www.medicareadvocacy.org/

The Center for Medicare Advocacy, founded in 1986, is a national, non-
partisan education and advocacy organization that works to ensure fair 
access to Medicare and to quality health care. At the Center, we 
educate older people and people with disabilities to help secure fair 
access to necessary health-care services. We draw upon our direct 
experience with thousands of individuals to educate policy-makers about 
how their decisions affect the lives of real people. Additionally, we 
provide legal representation to ensure that people receive the health-
care benefits to which they are legally entitled and the quality health 
care they need.

Many Medicare beneficiaries have chronic conditions and need a range of 
health-care services in a variety of health-care settings in order to 
maintain their functional status and to avoid unnecessary and costly 
hospitalizations. As discussed below, the Center for Medicare Advocacy 
submitted recommendations on chronic care reform to the Senate Finance 
Committee on June 22, 2015, which we summarize below. We focus in this 
Statement on Jimmo v. Sebelius, a nationwide class action lawsuit 
addressing Medicare coverage of maintenance nursing and maintenance 
therapy, an issue of particular concern to Medicare beneficiaries who 
have chronic conditions.

Finance Committee's Request for Comments on Chronic Care Reform

In response to the Committee's request for comments on chronic care 
reform, the Center for Medicare Advocacy submitted a number of 
recommendations on June 22, 2015.\1\ Among the Center's key 
recommendations were the need to assure full implementation of Jimmo; 
integration of oral health into covered and coordinated health-care 
services; removing current barriers to medically necessary care, such 
as therapy caps and the 3-day prior hospitalization requirement for 
coverage of post-acute care in a skilled nursing facility (SNF); 
integration of prescription drug coverage into traditional Medicare; 
streamlining payment systems to provide incentives for appropriate 
care; opposing site-neutral payments for different types of care; 
protecting Medicare beneficiaries from cost-shifting; improving access 
to care in Medicare Advantage and Part D plans by improving the 
administration of utilization management tools and beneficiary appeals 
processes; and assuring high quality care in all settings.
---------------------------------------------------------------------------
    \1\ The full set of recommendations is available at http://
www.medicareadvocacy.org/center-comments-to-senate-finance-committee-
regarding-chronic-care-reform/.
---------------------------------------------------------------------------

Jimmo and the Maintenance Level of Care and Services

Despite the Medicare program's long-standing recognition that Medicare 
coverage is appropriate to maintain a patient's functioning,\2\ a myth 
developed among health-care providers and Medicare adjudicators that 
Medicare covers care and services only if a beneficiary is expected to 
improve.
---------------------------------------------------------------------------
    \2\ See, for example, 42 CFR Sec. 409.32(c) (``Even if full 
recovery or medical improvement is not possible, a resident may need 
skilled services to prevent further deterioration or preserve current 
capabilities'') and 42 CFR Sec. 409.33(c)(5) (Maintenance 
rehabilitation therapy is a covered service ``. . . when the 
specialized knowledge of a qualified therapist is required to design 
and establish a maintenance program based on an initial evaluation and 
periodic assessment of a resident's needs . . .'').

On January 18, 2011, the Center for Medicare Advocacy and Vermont Legal 
Aid filed a nationwide class action lawsuit to dispel the myth and to 
assure that patients in both traditional Medicare and Medicare managed 
car--in skilled nursing facilities, home care, and outpatient therapy--
receive medically necessary nursing and therapy services to maintain 
their function and to prevent or slow their decline or deterioration. 
Jimmo v. Sebelius, Civ. No. 11-cv-17 (D. Vt. Jan. 18, 2011). Six 
organizations representing beneficiaries with chronic conditions--
Alzheimer's Association, National Multiple Sclerosis Society, National 
Committee to Preserve Social Security and Medicare, Paralyzed Veterans 
of America, Parkinson's Action Network, and United Cerebral Palsy--were 
also plaintiffs, illustrating the particularly harsh effects of the 
myth of improvement on people with chronic conditions. Although 
Parkinson's, for example, will not ``go away,'' as an acute condition 
might, patients with Parkinson's may need nursing care or therapy 
services in order to slow the inevitable course of their disease and to 
---------------------------------------------------------------------------
keep them functioning at the highest level possible.

Jimmo was settled by the parties in October 2012. Chief Judge Christina 
Reiss of the Federal District Court in Vermont approved the Settlement 
on January 24, 2013. Relevant language from the settlement confirms 
Medicare coverage for medically necessary maintenance therapy services 
at skilled nursing facilities, home health, and outpatient therapy:

        [U]nder the SNF, HH, and OPT maintenance coverage standards, 
        skilled therapy services are covered when an individualized 
        assessment of the patient' s clinical condition demonstrates 
        that the specialized judgment , knowledge, and skills of a 
        qualified therapist (``skilled care'') are necessary for the 
        performance of a safe and effective maintenance program. Such a 
        maintenance program to maintain the patient's current condition 
        or to prevent or slow further deterioration is covered so long 
        as the beneficiary requires skilled care for the safe and 
        effective performance of the program. When, however, the 
        individualized assessment does not demonstrate such a necessity 
        for skilled care, including when the performance of a 
        maintenance program does not require the skills of a therapist 
        because it could safely and effectively be accomplished by the 
        patient or with the assistance of non-therapists, including 
        unskilled caregivers, such maintenance services will not be 
        covered under the SNF, HH, or OPT benefits.\3\
---------------------------------------------------------------------------
    \3\ Jimmo v. Sebelius, Civ. No. 11-cv-17, IX 6 (D.Vt. January 18, 
2011), http://www.medicareadvocacy.org/wp-content/uploads/2012/12/
Jimmo-Settlement-Agreement-000117
64.pdf.

Similar maintenance language addresses nursing services.\4\
---------------------------------------------------------------------------
    \4\ Id., IX 8.

The New York Times heralded the settlement in an editorial as a 
``humane Medicare rule change'' that may even lead to savings.\5\
---------------------------------------------------------------------------
    \5\ Editorial, ``A Humane Medicare Rule Change,'' The New York 
Times (October 24, 2012), http://www.nytimes.com/2012/10/24/opinion/a-
humane-medicare-rule-change.html.

That prediction has indeed proven true. The Center for Medicare 
Advocacy spoke with the director of rehabilitation at a home care 
agency based in Michigan that has provided maintenance home care 
services to its clients since the Jimmo settlement. The company reports 
that the rate of hospitalization of its patients declined from 32.0% to 
---------------------------------------------------------------------------
14.2% over the past 3 years.

If Medicare beneficiaries with chronic conditions receive medically 
necessary and appropriate maintenance nursing care and therapy services 
and are able to avoid some hospitalizations as a result, both 
beneficiaries and the Medicare program benefit. Beneficiaries can 
receive medically necessary nursing care and therapy without being 
hospitalized and the Medicare program can achieve substantial savings. 
There is no question that many home health visits, outpatient therapy 
services, and even days in a SNF can be covered for the cost of a 
single day in the hospital.

Barriers to Full Implementation of Jimmo

Proper implementation of the Jimmo settlement should lead to improved 
Medicare coverage of care for all Medicare beneficiaries, including 
those who have chronic conditions. Unfortunately, we continue to hear 
regularly from beneficiaries who are denied maintenance coverage 
because they ``are not improving'' or have ``plateaued.'' Some of these 
inappropriate denials of coverage and care occur because of public 
policies that limit the effectiveness of the settlement. These policies 
include Medicare payment policies, quality reporting measures, and 
fraud investigations that target appropriate maintenance activities, 
among other activities.

For example, proposed quality reporting measures for SNFs, as required 
by the IMPACT Act, reflect solely an expectation of improvement. (The 
May 4, 2017 Notice of Proposed Rulemaking contains such language as 
``Residents receiving care in SNFs include those whose illness, injury, 
or condition has resulted in a loss of function, and for whom 
rehabilitative care is expected to help regain that function'').\6\ 
Although many individuals go to SNFs with an expectation of 
improvement, improvement is not the sole purpose of therapy in a SNF. 
Jimmo also recognizes that many residents may need physical, 
occupational, or speech therapy in order to maintain their function and 
to prevent or slow their decline. By evaluating, measuring, and 
reporting SNFs' performance solely on an improvement scale, however, 
the proposed quality measures undermine Medicare beneficiaries' ability 
to receive therapy for necessary and legitimate maintenance purposes. 
Maintenance goals must be included as additional appropriate quality 
measures for SNFs.
---------------------------------------------------------------------------
    \6\ 82 Fed. Reg. 21014, 21048-21049 (May 4, 2017), https://
www.gpo.gov/fdsys/pkg/FR-2017-05-04/pdf/2017-08521.pdf.

Similarly, audits may have targeted legitimate maintenance goals. In 
2010, the Inspector General issued a report, Questionable Billing for 
Medicare Outpatient Therapy Services, which was based on the premise 
that outpatient therapy is intended solely ``to improve a beneficiary's 
functional level.'' \7\ ``Questionable'' billing practices identified 
by the Inspector General included billing for therapy services 
throughout a year, rather than for a limited period of time, and 
billing that exceeded the annual therapy caps--factors that could 
reflect ongoing, legitimate, and appropriate maintenance therapy. 
Following issuance of the national report, which was based on the 
language of the pre-Jimmo Medicare Manual, the Inspector General 
conducted a series of audits of therapy providers who provide 
outpatient therapy services to Medicare beneficiaries under Part B. In 
one such report, for example, the Inspector General describes as the 
sole purpose of physical therapy--``to restore maximal functional 
independence to each individual patient by providing services that aim 
to restore function, improve mobility, and relieve pain.'' \8\ The 
audit found fault with the therapist's billing for a patient for whom 
``There was no expectation of significant improvement within a 
reasonable and predictable period of time.'' \9\ The audits' failure to 
recognize the legality of maintenance therapy as appropriate for 
Medicare Part B coverage undermines the provision of medically 
necessary and appropriate maintenance therapy.
---------------------------------------------------------------------------
    \7\ OEI-04-09-00540 (December 2010), https://oig.hhs.gov/oei/
reports/oei-04-09-00540.pdf.
    \8\ HHS Inspector General, A South Texas Physical Therapy Practice 
Claimed Unallowable Medicare Part B Reimbursement for Outpatient 
Therapy Services, A-06-14-00064, page 1 (June 2016), https://
oig.hhs.gov/oas/reports/region6/61400064.pdf.
    \9\ Id. 4.

Thank you for the opportunity to submit comments on Medicare policies 
to improve care for patients with chronic conditions. As a final 
comment, we urge Congress to add any new benefits and opportunities for 
improved care and coordination to traditional Medicare that are added 
---------------------------------------------------------------------------
to Medicare Advantage.

Toby S. Edelman
Senior Policy Attorney
Center for Medicare Advocacy
[email protected]

                                 ______
                                 
  College of Healthcare Information Management Executives (CHIME) and 
Association for Executives in Healthcare Information Technology (AEHIT)
The College of Healthcare Information Management Executives (CHIME) and 
the Association for Executives in Healthcare Information Technology 
(AEHIT) are pleased to submit a statement for the record of the May 16, 
2017, Committee on Finance hearing entitled, ``Examining Bipartisan 
Medicare Policies that Improve Care for Patients with Chronic 
Conditions.'' We appreciate the committee's interest in this timely 
issue and welcome the opportunity to offer perspective from the 
nation's healthcare chief information officers and chief technology 
officers on how technology can be leveraged to improve care for 
patients with chronic conditions.

CHIME is an executive organization serving more than 2,300 CIOs and 
other senior health information technology leaders at hospitals and 
clinics across the nation. CHIME members are responsible for the 
selection and implementation of clinical and business technology 
systems that are facilitating health-care transformation. Within CHIME 
is AEHIT, an organization launched in 2014 which represents more than 
300 chief technology officers and provides education and networking for 
senior technology leaders in health care. CHIME and AEHIT members 
represent some of the earliest and most prolific adopters of electronic 
health records (EHRs) and other health IT resources, such as telehealth 
as a means to improve patient care and outcomes.

Several converging factors present federal regulators and congressional 
leaders with a unique opportunity to pursue and implement policies to 
bolster the digital infrastructure that will play a pivotal role in 
transforming care delivery for patients, especially those with chronic 
conditions. The committee's consideration of the Creating High-Quality 
Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 
2017 is timely, as opportunities exist to enhance care delivery by 
modernizing federal policies to enable existing technology to augment 
the current care delivery paradigm.
Expanding Access to Telehealth for the Chronically Ill
Telehealth technologies offer a multitude of benefits to patients and 
clinicians alike. Telehealth and remote monitoring services are being 
leveraged in a variety of ways to meet patient care needs, especially 
those with chronic conditions. For instance, disease monitoring 
services can be less expensive, more efficient and more convenient for 
patients with chronic conditions or multiple co-morbidities to stay 
connected with their care team.

Adequate reimbursement for hospitals and other health-care providers 
for employing such services is a complex and evolving issue and, thus, 
has been a barrier to standardizing the provision of these valuable 
services. Efforts to revamp the federal Medicare telehealth policies 
have lagged behind both state and private payers as well as within the 
Department of Veterans Affairs (VA). Federal leadership is necessary as 
providers and health systems explore alternative care models to 
accommodate and encourage innovation and efficiency in health-care 
delivery.

A great deal of innovation is underway to develop health-care 
technologies that meet consumer needs often outside traditional care 
settings. These and other new technologies will be critical for 
advancing provider success in alternative payment models (APMs) and 
across federal reimbursement programs. Congress must pursue 
opportunities to incent and support the use of new and innovative 
technologies, rather than impede them as some existing federal policies 
do today.

The provisions in the CHRONIC Care Act that would enable expanded 
access to telehealth under Medicare Advantage (MA) plans and in 
Accountable Care Organizations (ACOs) serve as incremental, but 
important, steps to improving telehealth access for patients and 
revisiting the inadequacies in federal reimbursement for services. 
Further, the expansion of telehealth services for use in home dialysis 
under Section 102 would also be a positive step forward.

Specifically, Section 305, Expanding Use of Telehealth for Individuals 
with Stroke, would be of value to the industry as access to telestroke 
services grows. The benefits of leveraging telehealth to identify and 
administer early treatment to individuals suffering a stroke are 
indisputable. While telestroke programs are common, there is still room 
for growth.

CHIME and AEHIT members support \1\ the Creating Opportunities Now for 
Necessary and Effective Care Technologies (CONNECT) for Health Act \2\ 
(S. 1016). We encourage the committee to consider if any of the CONNECT 
for Health Act provisions could be included in the CHRONIC Care Act or 
if a broader telehealth bill could be considered this Congress.
---------------------------------------------------------------------------
    \1\ https://chimecentral.org/wp-content/uploads/2014/11/CHIME-
AEHIT-Letter-of-Support-for-Connect-for-Health-Act-2017-.pdf.
    \2\ https://www.congress.gov/115/bills/s1016/BILLS-115s1016is.pdf.

The committee should also consider how to address cross-state licensure 
concerns, often imposing troublesome legal barriers to a physician 
wishing to offer telehealth services to a patient in another state. 
Policies should allow licensed health-care providers to offer services 
to patients, using telemedicine, regardless of what state a patient 
resides in, notwithstanding whether the patient is within a traditional 
care setting or in one's home.
Improving Chronic Care Through Interoperability
A high degree of data fluidity is imperative for reducing waste and 
improving quality within the U.S. health-care system. Chronically ill 
patients are likely treated by numerous health-care providers across 
the continuum, making the need for policies that foster 
interoperability and meaningful data exchange even more critical. The 
adoption and use of electronic health records (EHRs) has resulted in 
the mass digitization of patient data, and with proper policies to 
enhance health data exchange, can revolutionize a provider's timely 
access to a patient's health history. Important policy goals such as 
advancement of team-based care, identifying chronically ill populations 
and empowering individuals and caregivers, will not be possible unless 
we are able to confidently and consistently identify patients.

The 21st Century Cures Act \3\ declared Congress's interest in an 
interoperable health IT infrastructure. The committee should encourage 
the Office of the National Coordinator for Health IT (ONC) to include 
chronic care as they establish and set the agenda for the new Health 
Information Technology Advisory Committee. Understanding how current 
technology can be used to improve chronic care as well as to evaluate 
current shortcomings, such as the lack of ubiquitous interoperability 
and meaningful data exchange, should be an area of work for the new 
advisory committee.
---------------------------------------------------------------------------
    \3\ https://www.congress.gov/114/bills/hr34/BILLS-114hr34enr.pdf.

Patient Identification for Chronic Care
Robust health histories and the ability to track patients who could be 
at risk to develop a chronic condition will be invaluable for 
prevention and treatment. The concept of a longitudinal health-care 
record should reflect the patient's experience across episodes of care, 
payers, geographic locations and stages of life. It should consist of 
provider-, payer-, and patient-generated data, and be accessible to all 
members of an individual's care team, including the patient, in a 
single location, as an invaluable resource in care coordination. 
Without a standard patient identification solution, the creation of a 
longitudinal care record is simply not feasible.

Congress acknowledged the lack of a national solution to identifying 
patient is an interoperability and patient safety issue in the FY17 
Omnibus Committee Report.\4\ Congress then went on to clarify that the 
ONC and the Centers for Medicare and Medicaid Services (CMS) can 
provide technical assistance to private-sector patient identification 
efforts.
---------------------------------------------------------------------------
    \4\ https://www.congress.gov/114/crpt/hrpt699/CRPT-114hrpt699.pdf.

Health-care technology has, and undoubtedly will continue to, alter how 
health care is delivered. As the committee considers how to improve the 
quality and efficiency of care for the chronically ill, we urge members 
to ensure that the federal policies in place enhance rather than hinder 
care delivery. CHIME and AEHIT members look forward to working with 
committee members, Congress, the Administration and all other 
stakeholders to explore how we can better prevent chronic illness, and 
---------------------------------------------------------------------------
treat those with chronic disease, with technology.

                                 ______
                                 
                   Connected Health Initiative (CHI)

                      1401 K Street NW, Suite 501

                          Washington, DC 20005

                              202-331-2130

                      http://www.connectedhi.com/

                              May 16, 2017

Hon. Orrin Hatch                    Hon. Ron Wyden
Chairman                            Ranking Member
Committee on Finance                Committee on Finance
U.S. Senate                         U.S. Senate
Washington, DC 20510                Washington, DC 20510

Dear Chairman Hatch and Ranking Member Wyden:

The Connected Health Initiative (CHI) represents a broad consensus of 
stakeholders spanning the health care and technology sectors who seek 
your partnership in realizing the benefits of an information and 
communications technology-enabled American health-care system. We 
commend your progress, including convening a hearing to examining 
bipartisan Medicare policies that improve care for patients with 
chronic conditions. We applaud your leadership in bringing forward the 
Creating High-Quality Results and Outcomes Necessary to Improve Chronic 
(CHRONIC) Care Act of 2017, which would take crucial steps to remove 
barriers to the use of telehealth, and we commit to work with you to 
move the country towards a more efficient and effective health-care 
system.

Today, more than 133 million Americans suffer from chronic conditions 
such as diabetes, chronic obstructive pulmonary disease, and mental 
illness. This population is expected to increase to approximately 171 
million by 2030. America's health-care spending is expected to reach 
$3.5 trillion in 2017, representing 18 percent of the entire U.S. 
economy, and this spending number is projected to reach 20 percent of 
the economy by 2025. A strong and growing body of evidence has clearly 
demonstrated that the wide array of connected health technologies 
available today improve patient care, reduce hospitalizations, help 
avoid complications, and improve patient engagement, particularly for 
the chronically ill. Further, the integration of these connected health 
technologies has been proven to reduce health-care costs significantly. 
Today, these connected health innovations represent a main driver in an 
Internet of things (IoT) marketplace valued at over $250 billion in the 
United States. These tools, including wireless remote patient 
monitoring health and wellness products, mobile medical device data 
systems, converged medical devices, and cloud-based patient portals, 
are revolutionizing the health-care care industry by allowing the 
incorporation of patient-generated health data (PGHD) into the 
continuum of care. Further, these advanced products and services 
present the ability to improve research and bring about the faster 
development of new therapies and cures and to improve meaningfully the 
lives of the American populations most in need today, such as veterans 
and those who live in rural areas. A 21st-century health-care system 
must integrate and embrace these innovative technologies to improve 
patient care and lower costs.

As a community, we believe that any legislation aimed at improving the 
American health-care system should reflect the benefits today's 
technology offers by permitting caregivers and patients to flexibly 
utilize innovations already used in many other facets of their lives to 
improve patient health care and lower costs. Despite the proven 
benefits of connected health technology to the American health-care 
system, U.S. government policies have largely ignored these solutions. 
For example, due to Centers for Medicare and Medicaid Services (CMS) 
policies that have remained unchanged for over 16 years, Medicare 
``telehealth'' reimbursements are minuscule (e.g., $14 million in 
2014), and remote monitoring technologies are ignored. You can move 
away from the backward-facing and outdated policies regarding the use 
of connected health technology in place today. We seek a partnership 
with you in revisiting these policies, and we are confident that our 
unique viewpoints and experiences can lend practical and innovative 
insights.

We also urge you to consider further opportunities to improve the lives 
of countless Americans with chronic conditions by leveraging connected 
health innovations. Specifically, we urge you to consider incorporating 
key provisions of the recently reintroduced Creating Opportunities Now 
for Necessary and Effective Care Technologies (CONNECT) for Health Act, 
which has been spearheaded by Senators Schatz, Wicker, Cochran, Thune, 
Cardin, and Warner, into the CHRONIC Care Act. The CONNECT for Health 
Act provides a carefully crafted approach to helping countless Medicare 
recipients realize the benefits of connected health technology by 
lifting arduous limitations on the use of telehealth, as well as 
empowering Medicare physicians to utilize remote monitoring 
technologies. While we support the passage of the CONNECT for Health 
Act as standalone legislation, incorporating all provisions from it 
into the CHRONIC Care Act would augment the latter, and would ensure 
that responsible and secure connected health solutions may be 
incorporated more broadly throughout the continuum of care to improve 
patient health outcomes.

Led by you, the 115th Congress has a historic opportunity to make the 
American healthcare system the greatest in the world by leveraging the 
wide array of connected health technologies available today, as well as 
paving the way for future innovations, through the CHRONIC Care Act. We 
are dedicated to realizing the potential of use of connected health 
technology solutions to improve the U.S. healthcare system, and we 
welcome the opportunity to assist you in any way.

Sincerely,

Morgan Reed
Executive Director
Connected Health Initiative
[email protected]

                                 ______
                                 
                 Health Care Transformation Task Force

                  601 New Jersey Avenue, NW, Suite 450

                          Washington, DC 20001

June 9, 2017

U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200

The Health Care Transformation Task Force \1\ applauds the Chronic Care 
Working Group for its efforts in advancing bipartisan Medicare policies 
to improve care for beneficiaries with chronic conditions. In 
particular, the Task Force supports the recently reintroduced Creating 
High-Quality Results and Outcomes Necessary to Improve Chronic 
(CHRONIC) Care Act of 2017 (S. 870) as a stepping stone to improved 
quality of care through value-based payment arrangements.
---------------------------------------------------------------------------
    \1\ The Health Care Transformation Task Force (Task Force) is a 
consortium of private-sector stakeholders that to accelerate the pace 
of delivery system transformation. Representing a diverse set of 
organizations from various segments of the industry--currently 
including patients, payers, providers, and purchasers--we share a 
common commitment to transform our respective business and clinical 
models to deliver the high quality, person-centered care at a lower 
cost. Our organizations aspire to put 75 percent of their business into 
value-based arrangements that focus on the Triple Aim of better health, 
better care and lower costs by 2020. We hope to provide a critical mass 
of policy, operational, and technical support from the private sector 
that, when combined with the work being done by CMS and other public 
and private stakeholders, can increase the momentum of delivery system 
transformation.

In previous correspondence with the Working Group (February 2016),\2\ 
the Task Force indicated its support for refinement of the CMS-
Hierarchical Conditions Category (HCC) model to account for 
interactions between behavioral and mental health conditions and 
physical health outcomes. The Task Force is encouraged by the 
implementation of this policy as well as the implementation of 
additional provisions of the Working Group's Discussion Draft.
---------------------------------------------------------------------------
    \2\ http://hcttf.org/resources-tools-archive/2016/2/1/task-force-
letter-to-senate-flnanee-committee-on-chronic-care-poIicy-options.

The following comments focus on our priority policy options within the 
CHRONIC Care Act of 2017, with a particular focus on efforts that 
advance our members' collective goal of putting 75 percent of our 
business into value-based payment arrangements by 2020, and promote the 
broader private sector movement toward value-based care. We encourage 
the Committee to continue this important work and look forward to 
additional legislation that would provide for more impactful 
improvements to Accountable Care Organizations than the provisions 
included in the current bill.

I. Expanding Innovation and Technology

      a.  Adapting Benefits to Meet the Needs of Chronically Ill 
Medicare Advantage Enrollees

    Provider networks and Medicare Advantage plans should be able to 
tailor care to beneficiaries who are chronically ill in ways that best 
meet their needs. These types of flexibilities will improve clinical 
outcomes, slow disease progression, and minimize barriers to quality 
care. We support the Committee's proposal to expand the testing of the 
CMMI VBID Model to allow a MA plan in any state to participate in the 
model by 2020, and also ask that this expansion apply to Employer Group 
Waiver Plans (EGWPs) within Medicare Advantage. Achieving savings 
without negatively impacting quality is a core goal of the 
transformation to value-based payment arrangements, and the VBID Model 
shows promise in this space. The testing phase will be important to 
determine if the supplemental benefits offered under the VBID model not 
only reduce barriers to care for high need individuals, but stimulate 
positive health outcomes while reducing overall costs. To that end, the 
Task Force also supports increased flexibility within the VBID model to 
allow MA plans to make positive benefit changes mid-year in order to 
best meet the needs of their chronically ill beneficiaries.

      b.  Expanding Supplemental Benefits to Meet the Needs of 
Chronically Ill Medicare Advantage Enrollees

    The use of supplemental benefits for chronically ill Medicare 
Advantage enrollees is a patient-centered approach to care that the 
Task Force supports. Enhanced benefits that would be especially 
beneficial include those that address barriers to effective treatment. 
Many of these benefits are not currently covered under the Medicare 
program given that they are not primarily health-related services 
(i.e., social services). Important examples of supplemental benefits 
that address the social determinants of health and reduce barriers to 
care include transportation, meal services, and exercise and wellness 
programs. All of these approaches have been known to improve health and 
overall function as specified by the proposal. We encourage specific 
inclusion of these services in the bill as examples of supplemental 
benefits that would be able to be offered in the MA program under the 
current proposal.

    We also ask that the Committee consider allowing MA plans to offer 
``benefits in lieu of benefits'' (i.e., substituting a needed benefit 
for an unnecessary one, as already offered under commercial plans). 
This type of flexibility would incentivize use of VBID within Medicare 
Advantage, and would allow plans to offer enhanced benefits to targeted 
enrollees. This policy is well-aligned with the Committee's proposal to 
expand supplemental benefits in MA, as it encourages plans and 
providers to work together to meet the needs of chronically ill 
individuals in the most efficient and effective way possible.

      c.  Providing Accountable Care Organizations the Ability to 
Expand Use of Telehealth

    Telehealth has moved beyond an innovative approach to beneficiary 
access to provider services, and has become a part of routine care 
models. The Task Force therefore supports the extension of the NextGen 
ACO telehealth waiver to all MSSP tracks, so that provision of 
telehealth services under value-based payment arrangements is not 
unnecessarily limited. We believe that telehealth payments should not 
be restricted geographically. We also believe that the originating site 
requirement should be eliminated entirely for ACOs and other similar 
risk bearing entities. With the assumption of risk, ACOs and other 
entities are held accountable for unnecessary utilization and waste, 
and therefore should not be restricted in their ability to provide 
telehealth services. Further, ACOs and other similar entities are held 
accountable for quality of care of their attributed patient population, 
and are therefore incentivized to provide face-to-face encounters with 
patients when it is clinically necessary.

    The Task Force also supports the provision of telehealth services 
to patients in their home, as this reduces barriers to care for many 
patients who have mobility or transportation limitations. Bringing care 
to patients where they are follows a 
patient-centered approach that will likely improve clinician-patient 
relationships and increase adherence to treatment/therapy plans, all 
while lowering the cost of care. We recommend that the CHRONIC Care Act 
reference the language and principles included in the CONNECT for 
Health Act (S. 2484/H.R. 4442), which was informed by the experiences 
of multiple provider organizations.

II. Identifying the Chronically Ill Population

      a.  Providing Flexibility for Beneficiaries to Be Part of an 
Accountable Care Organization

    Allowing Medicare FFS beneficiaries to voluntarily elect to be 
assigned to the ACO, or other similar risk-bearing entity, in which 
their main provider is participating will increase the number of 
beneficiaries participating in the program, and the amount of care 
subject to value based payment arrangements. Given that Task Force 
members are committed to transitioning away from fee-for-service, we 
support increased participation in ACOs and other risk models. 
Voluntary alignment is an important component of a robust attribution 
model, which itself is necessary for accepting accountability for a 
population of patients. A robust attribution model is one that reflects 
a patient declaration of ``Yes, this is my provider group'' and a 
provider group declaration of ``Yes, this is our patient.'' Robust 
attribution makes a population ``more known,'' and if ACO attribution 
is maintained and shared by a payer (including Medicare), it can be 
used to support information exchange, optimize care coordination, and 
align incentives across all providers. Simply allowing patients to 
voluntarily elect to be part of an ACO is not enough, however. ACOs 
must actively engage in outreach and education that will help patients 
better understand the benefits and implications of participation.

III. Empowering Individuals in Care Delivery

      a.  Eliminating Barriers to Care Coordination Under Accountable 
Care Organizations

    The Task Force emphasizes that meaningfully engaging beneficiaries 
as partners in care and delivering patient-centered care that meets the 
needs of patients and families is the best way to encourage 
beneficiaries to consistently seek care within their ACO and access 
preventive care or disease management as needed. As proposed, a flat 
rate payment to Medicare FFS beneficiaries under the ACO Beneficiary 
Incentive Program would not effectively impact the highest-need, 
highest-cost population. The Task Force supports policies that lower 
the out-of-pocket cost burden for beneficiaries, but believes that 
these supports should reflect the amount and level of acuity of care. 
For example, a previous proposal by the Chronic Care Working Group 
contemplated waiving cost-sharing for items/services that treat a 
chronic condition or prevent the progression of a chronic disease. The 
Task Force is supportive of this approach, as it more directly 
addresses the needs of those with chronic illness by correlating with 
each patient's out-of-pocket burden.

Thank you for the opportunity to provide this comment. Please contact 
Task Force Executive Director Jeff Micklos ([email protected], 
202-774-1415) or Caitlin Sweany, Director of Transformation 
Facilitation and Support (caitlin.sweany
@hcttf.org, 510-506-8972) with any questions.

                                 ______
                                 
                          Juniper Communities

                          400 Broadacres Drive

                          Bloomfield, NJ 07003

                              973-661-8300

                            973-661-8333 Fax

                   http://www.junipercommunities.com/

May 23, 2017

U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200

Dear Mr. Chairman,

I'm pleased to submit for the record the results of a study we 
commissioned examining the impact of integrated care for chronically 
ill, functionally impaired seniors living in seniors housing.

Background

According to the Partnership to Fight Chronic Disease, more than 190 
million Americans, or about 59 percent of the population, are affected 
by one or more chronic illness. Over the next 15 years (between 2016 
and 2030), 80 percent of the U.S. population will experience one or 
more chronic conditions, costing more than $42 trillion in medical care 
spending and losses in employment productivity. The frail elderly 
population in the United States suffers from multiple chronic 
conditions, uses the most health-care services and, not surprisingly, 
drives most of the costs in our health-care system. As baby boomers 
continue to age, millions more Americans will join this vulnerable 
population, adding additional pressure to deliver quality outcomes at 
the lowest cost.

Findings

Bloomfield, NJ-based Juniper Communities--an owner and operator of 
senior communities in New Jersey, Pennsylvania, Florida, and Colorado--
developed a model called Connect4Life, which promotes the integration 
of housing and supportive services with clinical care to prevent 
illness and restore well-being. New research by Anne Tumlinson 
Innovations demonstrates that Connect4Life contributed to better 
clinical outcomes for frail seniors and suggests the potential for 
Medicare cost savings.

Compared to the 2012 Medicare Beneficiaries Survey (MCBS), Juniper 
Communities' population is older, frailer and more cognitively impaired 
than the research study's cohorts: all Medicare beneficiaries, frail 
individuals living in the community and similarly frail individuals in 
other seniors housing communities. Nevertheless, Juniper's performance 
on key clinical measures was determined to be significantly better than 
the performance of a similarly frail Medicare population:

  The hospitalization rate was 50% lower.
  The re-hospitalization rate was over 80% lower.
  Emergency department use was 15% lower.
  Juniper's residents also used fewer services.

The Connect4Life model features three key components, each of which 
contributed to these results:

1. Co-located services. Connect4Life provides on-site delivery of 
primary care and other clinical services, such as comprehensive 
therapy, pharmacy, and lab services, which fosters prevention and cost 
savings.

2. Coordinated record keeping. The model utilizes one electronic health 
record that must be used by all providers to share clinical data and 
performance on various quality metrics. This allows common access to 
real-time information, increased transparency, and better care 
coordination.

3. Human touch. A human navigator connects patients to caregivers and 
drives communication between all providers. The navigator also ensures 
seamless access to and coordination with other services provided 
through strategic partnerships and alliances.

Research Implications

Juniper Communities' Connect4Life model affirms the value of 
integrating clinical care and supportive services in a seniors housing 
environment to manage population health--in this case, Medicare 
beneficiaries with chronic conditions, functional limitations and 
complex social needs. Connect4Life presents a unique opportunity to 
create value for frail seniors and their families, government, and 
seniors housing operators.

For the full white paper, visit http://www.junipercommunities.com/.

                                 ______
                                 
           National Association of Specialty Pharmacy (NASP)
    The National Association of Specialty Pharmacy (NASP) appreciates 
the hard work of the Chronic Care Working Group and thanks the 
Committee on Finance for holding this important hearing to improve care 
for patients with chronic conditions; we submit the following written 
testimony for the record. NASP is a 501(c)(6) non-profit trade 
organization serving as the unified voice of specialty pharmacy in the 
United States and dedicated to education, national policy advocacy, and 
engagement of all stakeholders in the specialty pharmacy industry. Our 
focus is on specialty drugs, or medications, which are more clinically 
complex than most prescription medications and are used to treat 
patients with serious, chronic and often life threatening or life 
altering conditions including cancer, hepatitis C, rheumatoid 
arthritis, HIV/AIDS, multiple sclerosis, cystic fibrosis, organ 
transplantation, human growth hormone deficiencies, hemophilia, and 
other bleeding disorders.\1\
---------------------------------------------------------------------------
    \1\  The National Association of Specialty Pharmacy recently 
defined both Specialty Drug and Specialty Pharmacy: http://naspnet.org/
wp-content/uploads/2017/02/NASP-Defintions-final-2.16.pdf.

    A specialty drug may be classified as such due to the way it is 
administered, the side effect profile, the disease or condition it is 
used to treat, special access conditions required by the manufacturer, 
payer authorization or benefit requirements, patient financial 
hardship, special handling, or any combination of these. Based on these 
characteristics, the payer, provider, specialty pharmacy and/or the 
manufacturer can or will identify the therapy as requiring specialized 
services. As a result, specialty prescription medications cannot be 
routinely dispensed at a typical retail community pharmacy because the 
typical retail pharmacy does not have the required infrastructure to 
provide the patient care or other support services that specialty 
medications require. Specialty drugs are often confused as being only a 
``limited distribution drugs (LDD).'' This is not the case as there are 
---------------------------------------------------------------------------
specialty drugs that are not part of a limited distribution network.

    Historically, the cost of a medication has been used to designate a 
medication as specialty. Cost should not be the only reason a 
medication is classified as ``specialty.'' In fact, there are many low-
cost medications that are classified as specialty because of the unique 
and labor intensive services required to assure proper utilization and 
maximize the clinical outcome. For example, select generic oral 
chemotherapy medications and certain generic immunosuppressant 
medications require special handling processes and a comprehensive, 
coordinated care approach to ensure successful therapeutic outcomes 
similar to those of higher cost therapies. Even though these 
medications are low cost, they are still considered specialty therapies 
by plan sponsors. A medication's classification should be based on the 
services provided in support of the drug and/or disease state and not 
just its cost.

    The wide range of current specialty drugs require specialized 
services to ensure appropriate utilization, access and maximize patient 
outcomes. As a result of this growth and the emerging, evolving and 
expansive specialty drug pipeline, the practice of specialty pharmacy 
has also evolved. As more and more patients are living with chronic 
diseases for which just a few short years ago there were no effective 
treatment options available, the expert services that specialty 
pharmacies provide drive adherence and persistency, proper drug and 
disease management, mitigation of side effects, and dosing optimization 
ensuring clinically appropriate and safe medication use. The specialty 
pharmacy's patient-centric model is designed to provide a comprehensive 
and coordinated model of care for Medicare beneficiaries suffering from 
chronic illnesses and complex medical conditions achieve superior 
clinical outcomes, expedite patient access to care and positively 
impact the total cost of care for these most vulnerable of 
beneficiaries.

    Specifically, many specialty drugs require significant patient 
education on both the disease and the prescribed drug therapy. Many 
specialty pharmacists have specialized areas of clinical expertise, 
which the prescribing physician relies upon to help explain the nature 
of the disease and manage the patient's journey. Furthermore, this 
pharmacist then explains to the patient the prescribed regimen for the 
prescribed drug. It is through these services that the specialty 
pharmacist acts as an extension of the physician's office to educate 
the patient on his/her disease and empowers the patient to use the 
medication appropriately. This education is a very important part of 
improving beneficiary outcomes and reducing unnecessary drug spend.

    A specialty pharmacy is a state-licensed pharmacy that solely or 
largely provides medications for people with serious health conditions 
often chronic in nature requiring complex treatment plans and 
medications. In addition to being state-licensed and regulated, NASP 
believes that specialty pharmacies should also be accredited by 
independent third parties. Accreditation represents a commitment to 
quality, safety, accountability and the consistent delivery of quality, 
cost effective health care. Plan sponsors, health plans and other 
payors recognize the value of independent, third party accreditation 
and most often require this as a condition of participating pharmacy 
network provider participation. Accreditation organizations help 
pharmacies develop their specialty pharmacy capacity and verify their 
capabilities to manufacturers and third-party payers. Accreditation 
organizations create standards that are designed to create a consensus 
around the practice of specialty pharmacy and generally address four 
primary areas of specialty pharmacy practice, which encompass the 
overall provision of pharmacy care for patients receiving these 
medications. These areas of focus include the organizational 
infrastructure to support the provision of specialty pharmacy care, 
patient access to medications via manufacturer requirements and 
benefits investigation, clinical management of the patient, and 
quality.

    Specialty pharmacies serve a critical role in the healthcare 
delivery system because they connect patients who are chronically and 
often seriously ill with the medications that are prescribed for their 
conditions, provide the patient care support services that are required 
for these medications, and assist patients who are facing reimbursement 
challenges for these highly needed but also frequently expensive 
medications. Specialty pharmacies do not establish the price of the 
specialty drug, but are a significant partner in driving the value of 
the drug towards a successful therapeutic outcome.

    At present, these valuable patient-focused services are under 
substantial threat due to the assessment of fees that select pharmacy 
benefit managers and Medicare Part D Plan Sponsors began in 2015 for 
pharmacies participating in Medicare Part D networks. These fees, 
termed Direct and Indirect Remunerations (DIR) are charged against 
specialty pharmacies based on their performance in a number of primary-
care focused ``quality metric'' categories, which are totally unrelated 
and irrelevant to specialty pharmacies and patients they serve. The DIR 
fees have therefore morphed away from reflecting post point of sale 
price concessions (i.e., rebates) to the application of percentage 
based network participation fees being assessed against specialty 
pharmacies retroactively for performance with respect to quality 
metrics which do not apply to the specialty pharmacy nor does the 
specialty pharmacy have the ability to influence. This transition is 
threatening the specialty pharmacies' ability to continue to provide 
the high touch patient care support services that these patients and 
mediations require. This transition is so dramatic that in January 
2017, the Centers for Medicare and Medicaid Services (CMS) recognized 
the impact of these DIR fees,\2\ which have upended the overall 
pharmacy industry, clawing back the resources that fund comprehensive, 
coordinated patient care and support services, and stand to threaten 
the continued ability of independent specialty pharmacies to provide 
Medicare beneficiaries services critical to prescription drug adherence 
for complex medications. CMS and Congress should protect Medicare 
beneficiaries, and the Medicare budget, by ensuring that any DIR or 
other fees apply quality or performance measures that are reasonable 
and valid-until such is determined DIR fees should be suspended.
---------------------------------------------------------------------------
    \2\ https://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/
2017-fact-sheet-items/2017-01-19-2.html.

    In addition, to ensure optimal access to advanced clinical 
management services, NASP believes that each plan sponsor should 
disclose the specialty pharmacies that it has in-network for each of 
the formulary drugs within the oncology, immunomodulators, multiple 
sclerosis, HIV/AIDS, HepC and immunosuppressant classes. By doing so, 
CMS and Medicare beneficiaries will know which specialty pharmacies are 
in-network by drug and can therefore truly determine if each Medicare 
beneficiary has access to each of the formulary's specialty drugs. By 
adopting this process, the agency will also have greater visibility 
into the network adequacy of each plan. This visibility will help CMS 
ensure that each Medicare beneficiary will truly have access to their 
---------------------------------------------------------------------------
needed specialty medications regardless of the plan he or she chooses.

    Thank you again for holding this important hearing. We look forward 
to working with you on developing improvements to address barriers to 
high-value chronic care medical management via specialty pharmacy 
services. For more information please contact our Executive Director, 
Sheila Arquette, [email protected].

                                  [all]