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Move forward with federal budget agreement to advance care for adults with complex needs

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For all the disagreement that persists among federal policy makers on how to proceed with health care reform — most recently evidenced by the absence of Affordable Care Act fixes in the March 23 spending bill — the Bipartisan Budget Act of 2018 incorporated a little known, but highly significant, set of provisions to advance care for our nation’s sickest and frailest.

Passed by Congress and signed by President Trump in February, the budget deal includes the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care (CHRONIC Care Act).

{mosads}The legislation makes great strides in improving care for the most vulnerable patients who account for a large proportion of health care spending by expanding successful programs; giving Medicare managed care plans new flexibility to better care for these patients; and offering opportunities to expand tele-health services.


In any given year 5 percent of patients account for 50 percent of the nation’s health care expenditures. Many of these high-need, high-cost patients — people with two or more major chronic conditions, such as diabetes or congestive heart failure, and functional limitations that prevent them from performing routine activities of daily living — also have unmet social needs, like hardships obtaining housing, transportation, or food that may exacerbate their medical conditions.

The National Academy of Medicine (NAM), with support from the Peterson Center on Healthcare, recently released a publication that documented the challenges facing high-need, high-cost individuals; described effective strategies for improving care for them; and outlined policy options to better meet their needs.

Several of the NAM report’s policy recommendations, which were reviewed and researched by the Bipartisan Policy Center, were incorporated into the Bipartisan Budget Act of 2018.

Some of the key provisions of the CHRONIC Care Act that could benefit these high-need patients include:

  • Flexibility for Medicare managed care plans, known as Medicare Advantage (MA) plans, to cover non-medical services such as home-delivered meals or transportation to doctor’s appointments. The law allows plans to target these supplemental benefits to covered individuals based on their specific needs, whereas before, MA plans had to provide uniform coverage to all beneficiaries.
  • Expansion of promising and successful programs through Medicare, such as the Independence at Home program, which allows seniors with multiple, complex, and expensive chronic conditions to receive specialized care at home through a team of providers.
  • The law also permanently authorizes Special Needs Plans (SNPs), which limit membership to people with specific diseases or characteristics and are able to tailor their benefits, provider choices, and prescription plans to address the needs of the groups they serve.
  • Expansion of tele-health services, like video calls with a care provider, which could increase access to care and reduce unnecessary hospitalizations.

While this is a positive start, the devil is often in the details of implementation. As the law winds its way through the rule-making process, there will be important regulatory choices made by the Centers for Medicare and Medicaid Services (CMS) that will affect how successful the new law can be. For example, which social services will qualify as supplemental benefits in MA plans? Which services will be covered for tele-health?

Beyond CMS, it will also be important to monitor how the MA plan providers react. Will they take advantage of the flexibility and offer supplemental or enhanced services to high-need patients? And of course, everyone will be watching to see if these changes actually improve patient outcomes and lower costs of care.

Despite the progress spurred by the CHRONIC Care Act, there is more to be done. CMS currently does not adequately adjust their payment for care based on a patient’s cognitive or physical impairments, which are known to exponentially increase complexity of health services needed as well as the associated cost.

Greater understanding and recognition of the challenges that these patients face, often related to socioeconomic issues that impact their ability to access available services, is critical. Additional solutions are also needed to support family caregivers; to involve a wide variety of community organizations as partners in the care delivery process, especially around non-medical needs; and to address public and private strategies for financing delivery of long-term supports and services.  

Since social, functional, and behavioral needs are a critical part of the big picture of health for high-need individuals, policy makers could incentivize adoption of interoperable electronic health records that account for these factors.

The ability of clinicians to access and use comprehensive, real-time information about their patients, including information that captures the use of non-medical services such as homeless shelters, food banks, and harm reduction centers, will better enable clinicians to make decisions about what types of care may best help patients.

There is a great deal of opportunity for policy makers to take action to improve health care for these high-need individuals while helping lower care costs simultaneously. The solutions that are developed for this complex group of patients will add value across the entire health care delivery system, resulting in improvements for all patients and payers.

Let’s not lose momentum for improving care for some of the most vulnerable patients in our society while seizing the opportunity to control costs for everyone. Solutions are in sight. Now, bipartisan collaboration and action are needed. 

David Blumenthal, M.D., M.P.P., is president of The Commonwealth Fund, a national philanthropy engaged in independent research on health and social policy issues. Blumenthal is formerly the Samuel O. Thier Professor of Medicine at Harvard Medical School and Chief Health Information and Innovation Officer at Partners Healthcare System in Boston. Robin Wittenstein Ed.D., is the CEO of Denver Health, which is a one of Colorado healthcare institutions and home to the region’s level 1 trauma center.

Tags Chronic care management Donald Trump Federal assistance in the United States Health Health care Healthcare quality Healthcare reform in the United States Managed care Medicaid Medicare Patient Protection and Affordable Care Act Presidency of Lyndon B. Johnson

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