The do-nothing Congress may be doing
something. In the immediate aftermath of the Senate’s third and hopefully final
failure to “repeal and replace” the Affordable Care Act, the Senate actually
passed a health care bill unanimously. With little public fanfare, it approved
CHRONIC (the Creating High Quality Results and Outcomes Necessary to Improve
Chronic Care Act of 2017). This bill, if it is not eviscerated or rejected by
the House, takes a few important steps in the right direction.
As a useful summary in the Health Affairs blog explains, the bill supports changes in four domains: home based
care, managed care, telehealth, and accountability. In the arena of home based
care, the law extends the successful “independence at home” demonstration
project for two years, increasing the number of participants from 10,000 to
15,000. This is a relatively small modest program that does something
critically important for some of our sickest and most complex patients—it moves
the nexus of care from the hospital and the office into the home.
In the area of managed care, the law does
something quite remarkable. It incentivizes further use of Medicare Advantage
programs, a long-standing Republican objective since they see Medicare
Advantage as a way of privatizing Medicare. But one of the ways it does this is
to allow programs to expand benefits to include social supports and help with activities
of daily living. It’s a tiny wedge that could signal the beginning of a
recognition that social factors contribute to health. This is the message of
the book, The American Health Care Paradox by Elizabeth Bradley and Lauren
Taylor in which they argue that the reason Americans spend so much more per capita on
health care than any other developed nation—and achieve poorer results—is that
we substitute medical benefits for social benefits, to the detriment of
well-being. We are a long way from allowing federal money to be used to pay for
gardening supplies, say, so that a person with dementia would be happy
puttering around at home and not become agitated and restless, perhaps
triggering pharmacological treatment or even nursing home care, as has happened
in the UK. But it’s a start.
The telehealth expansion is another one
of those strategies, such as electronic medical records, that on the surface is
very appealing, but for which the evidence of effectiveness is mixed. It
feeds nicely into the conviction that there are technical fixes to the American
health care system, rather than major structural problems that must be
addressed. Probably not the best use of scarce resources, but not a terrible
idea.
Finally, the Act mandates that the GAO
carry out three investigations to assess the consequences of various strategies
that have been piloted or proposed. One of these is a special reimbursement
code for physicians to formulate a comprehensive care plan for patients with
certain serious conditions. Another is whether Medicare Part D should lift its
ban on drugs that help patients lose weight. The GAO is usually thorough and
unbiased in its evaluations. All sound efforts at systematic evaluation—as opposed
to wholesale, uncritical adoption of policies and programs—should be supported.
Will the House pass the bill? Will it
discover the most interesting parts of the legislation, ie the provision that
lets Medicare Advantage programs offer benefits that are not “medical” in the
conventional sense? We shall see. Tell your representative that if s/he wants
to take credit for something, this would be a good place to start.
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