Lawmakers To CMS: Move Forward On ‘Independence At Home’ Guidance

Inside Health Policy | By Amy Lotven

Sen. Ron Wyden (D-OR) and Rep. Edward Markey (D-MA) are urging CMS Acting Administrator Marilyn Tavenner to prioritize a health reform-mandated demonstration that allows Medicare to pay for home visits by physicians involving a small group of beneficiaries with specific chronic diseases. The lawmakers, in a recent letter to Tavenner, note that by statue the Independence At Home Act must be implemented by Jan. 1, 2012, and with just a few weeks left in the year no implementation information has been released.

Another health source familiar with the program tells Inside Health Policy that interested parties had also urged former CMS chief Donald Berwick to implement the program, but to no avail, even as CMS moved forward with other demonstrations that were not statutorily required.

CMS declined to comment on the issue, but several sources suggest that the agency will respond to the lawmakers soon.

In the letter, Wyden and Markey express concerns that that the delay may cause providers who had been interested in the IAH program to enroll in other shared savings programs. “This would be disastrous given that IAH utilizes a proven delivery model, which has been shown to dramatically improve patient care and satisfaction, while significantly reducing costs for chronically ill individuals,” they write.

“By law, IAH must be operational by Jan. 1, 2012,” Wyden and Markey wrote in their Dec. 7 letter. “Yet, with three weeks remaining in the year, CMS still has not released guidance for providers that wish to apply for participation, much less indicate that this model should be expanded beyond the 10,000 beneficiaries limit specified in the statute.”

Wyden expressed interest in allowing dually eligible beneficiaries to participate in the program during a September hearing with Melanie Bella, who heads CMS’ new duals office. Bella said that she would like to learn from the IAH program but noted that it was only for Medicare and not Medicare. However, she also said that she would look into how many of the 9 million duals might fit into such a program. According to Wyden, there is enough physician capacity to serve 2 million beneficiaries.

Wyden and Markey also told Tavenner that they had sent a letter to CMS in June laying out the criteria they felt were necessary for IAH to succeed. Berwick responded that the agency would take the information into consideration as staff developed guidelines, they write. The lawmakers, in their letter to Tavenner, reiterate support for their earlier design suggestions and ask when the guidance will be released.

The health source who has been tracking the IAH says CMS’ failure to take steps to implement the program is the first setback the program has encountered. The provision was included in the health law via a unanimous vote during the Senate Finance Committee markup, and the model has been seen as a success across the country, the source adds. The Veterans Administration has 25,000 participants nationwide, and has said that it could help CMS design the program, according to the source.

For those reasons, the source says, it is troubling that the previous administrator did not appear interested in the IAH. Berwick is on the lecture circuit now, so maybe some day he’ll let people know why he chose not to focus on a program that has been proven to work, adds the source.

Additionally, the source raises concerns that CMS has been moving forward with other health reform programs — like the Advanced Payment Accountable Care Organization Model — that dole out money to people for participating and do not ask for repayment, which the source finds counter to the direction that CMS should be taking.

Accountable Care Organizations are a “nice idea,” but they have not been proven to work, according to the source. Many participants in the Physician Group Practice demonstration, upon which the ACO program is based, didn’t even achieve the 2 percent savings, the source says.

Practices participating in the IAH must save at least 5 percent of what Medicare would otherwise spend and hit quality and patient satisfaction benchmarks.

Although Berwick was unresponsive to IAH supporters, the health source says that Tavenner has already been more engaged. “It’s like night and day,” says the source.

The health source is hopeful that the guideline will be out soon.

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