We must focus on Medicare’s most vulnerable and sickest patients

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Given the partisan gridlock gripping Washington and the continued debate over the Affordable Care Act, it can be hard to imagine common ground on healthcare. And yet, despite the many ideological differences between Republicans and Democrats, there is surprising agreement on our system’s shortcomings: Healthcare in the U.S. is wasteful and inefficient, and does a poor job caring for our nation’s most vulnerable citizens.

{mosads}The tough reality is that a small proportion of our country’s sickest citizens are driving a disproportionate share of healthcare spending. According to the Medicare Payment Advisory Commission, just 10 percent of Medicare beneficiaries account for almost 60 percent of annual Medicare fee-for-service (FFS) spending. One would hope that this enormous investment of resources is going toward high-value, high-impact care. Unfortunately, this is rarely the case. Our most vulnerable patients are not getting the best care.

The sickest 10 percent of Medicare beneficiaries are more likely to have multiple chronic conditions, such as kidney disease, heart failure and chronic obstructive pulmonary disorder (COPD). They are also more likely to be poor. What these patients need is seamless, coordinated care to properly manage their conditions and navigate a complex healthcare delivery system. What these patients get is a disorganized, disjointed experience that results in visits to numerous healthcare facilities, seeing sometimes dozens of providers and taking dozens of medications. It should come as no surprise that the Institute of Medicine has estimated that 30 percent of U.S. health spending is wasted on unnecessary services, burdensome procedures and excessive administrative costs.

The challenge is to find ways to pay for care based on its quality, rather than quantity. No longer is the question whether we must move to payment systems that reward value rather than volume; instead, the questions are when and how?

Nowhere is it more important to get this right than in Medicare. Today, over 55 million seniors and disabled Americans, or 17 percent of the U.S. population, receive their healthcare through the Medicare program. Current spending for the program is nearly $600 billion per year, a figure that is only expected to grow as 10,000 baby boomers turn 65 and age into Medicare each day.

The good news is that bipartisan legislation is currently pending in Congress to address the very specific needs of Medicare’s sickest (and costliest) beneficiaries. H.R. 3244, the Providing Innovative Care for Complex Cases Demonstration Act of 2015 (sponsored by GOP Rep. Cathy McMorris Rodgers of Washington state ) and its Senate companion, S. 2498, the Medicare Program Linking Uncoordinated Services (PLUS) Act (sponsored by Democratic Sen. Michael Bennet of Colorado), would establish a pilot program to test a new value-based payment and coordinated care delivery model to improve quality, reduce costs, and provide additional benefits for those Medicare FFS beneficiaries with the most complex and costly medical conditions.

Under the pilot program, participating health plans and accountable care organizations (ACOs) would be given the flexibility to spend Medicare dollars on care management, transportation, in-home assistance and in-home technology to improve beneficiary care. For example, a beneficiary leaving the hospital could receive a home visit from a nurse to go over the patient’s prescriptions and assess progress, as well as free transport to follow-up doctors’ appointments. Plans and ACOs would also be able to reduce or eliminate beneficiary co-pays and cost-sharing to improve care. Beneficiaries enrolled in this pilot would be served by an interdisciplinary care management team — quarterbacked by a nurse coordinator — to ensure they are getting the right care at the right time.

Importantly, not only would this pilot program improve care for Medicare’s sickest beneficiaries, but it would save taxpayer dollars: Participating plans and ACOs would be paid just 98 percent of the projected cost of treating this population under FFS Medicare. If the pilot program proves successful in the initial four geographic areas, it could be expanded to benefit even more enrollees.

We should not let partisan rhetoric overshadow the fact that our healthcare system is failing many of our nation’s most vulnerable citizens. We hope that members of both parties will agree that we can, and must, do better. Now is the time to begin, in earnest, to foster and implement integrated approaches to healthcare that improve quality and lower costs. Passing this bill is a good first step.

Daschle is a former Democratic senator from South Dakota and former U.S. Senate majority leader. Leavitt is a former secretary of Health and Human Services for the George W. Bush administration and was the governor of Utah from 1993 to 2003.

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