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Medicare Health Support: “Do not go gentle into that good night”

Vince Kuraitis and Thomas Wilson, PhD, DrPH

“Do not go gentle into that good night.
Rage, rage against the dying of the light”
Dylan Thomas

    

Despite CMS’ recent cocktail hour pronouncement that Medicare Health Support (MHS) is on its last legs, many are fighting to prolong its life.

Recent Developments

DMAA is working with Sen. John Kerry to introduce legislation mandating the continuation of Medicare Health Support (MHS).  Dr. Jaan Sidorov’s Disease Management Care Blog reprints the full announcement from the February 12 issue of DMAA eNews.  Here’s an excerpt:

An influential Senate lawmaker last week told a health policy publication that he would consider legislation to keep Medicare Health Support (MHS) operational past the scheduled end of the pilot’s first phase.

If he succeeds, Sen. John Kerry, D-Mass., would block a recent and controversial decision by the Centers for Medicare and Medicaid Services (CMS) to end the pilot this year without providing continuity of services to the 68,000 beneficiaries in MHS. In an unexpected announcement Jan. 29, CMS said it would begin closing out five MHS programs this summer as each reached the end of the three-year Phase I pilot. Transition to a second phase could be delayed up to three years while CMS evaluates Phase I results, the agency said.

Healthways has written a letter to CMS saying “We are hitting our MHS Phase 1 targets, get on with MHS Phase II.”  The letter was described in a Healthways’ press release issued February 13:

…the Company has delivered a letter to Kerry Weems, Acting Administrator of the Centers for Medicare and Medicaid Services (CMS) with respect to the Company’s performance in its Medicare Health Support (MHS) Phase I Pilot in Maryland and the District of Columbia. In the letter, Healthways calls into question both the content and the conclusions, as they relate to Healthways, of several CMS documents distributed by CMS on January 29th to Congress, the press and the financial community.
“The purpose of our communication with Acting Administrator Weems,” (CEO) Leedle stated, “was to affirmatively remind CMS that performance in MHS must be evaluated at the individual pilot, or pilot component level, not in the aggregate. Further, we continue to have a number of unresolved issues related to the design, beneficiary selection, randomization and other aspects of the Phase I pilots, including the fact that CMS did not deliver the pilot population that it was contractually obligated to provide. While ultimate resolution of these issues will impact the final results of our pilot, we believe, based on our analysis of the data that has been provided to us, our program or its components will meet or exceed the statutory and current Cooperative Agreement targets by which MHS performance is to be evaluated.”

How Should You Interpret These Developments?

The meaning of these events is not entirely clear. This is a situation in which all of us are smarter than any one of us, so we encourage you to add your own comments.  That said, we’ll offer our perspectives.

In the past, DMAA and the DM industry in general have had a constructive working relationship with CMS.  DMAA’s potential political solution and Healthways’ letter suggest that relationships today are more “rage, rage” than warm and fuzzy. 

It’s conceivable that the conflict could escalate further.  Healthways’ letter could be a precursor to a lawsuit asking a court to declare that they were “successful” in Phase I and ordering CMS to conduct MHS Phase II.  But what defines “success”?   As taxpayers, we make the same plea to Healthways and to CMS:   Show us the evidence! 

Given the ambiguity of the legislation enacting MHS, Healthways might also argue that successful participants in Phase I MHS should be given preferential treatment in contracting for Phase II.  This would challenge the interpretation made in the MHS Fact Sheet posted on the CMS website on January 29:

“If CMS does move to a Phase II, the Phase II awardees would be selected according to a new competitive process. Participation in Phase I would not guarantee an organization participation in Phase II.”

Finally, we detect a seismic shift in thinking about chronic care management at CMS.  In the early days of MHS we heard CMS refer to two schools of DM:  The “Vendorites” and the “Wagnerites.”   The “Vendorites” might have said:

“Doctors are just too difficult to work with.  It’s more effective to work directly with patients to help them manage their own conditions.”

The “Wagnerities” (referring to Dr. Ed Wagner’s Chronic Care Model) might have said:”

“Doctors are integral — even central — to the care management process.  Doctors should deliver and reinforce messages to patients that they need to be more involved in managing their own conditions.”

You might remember that all the awardees of MHS projects were health plans or DM companies — not physicians, hospitals, home health agencies or other local care providers.  The “Vendorites” won.

Today’s thinking at CMS seems to be much more leaning toward the “Wagnerites”.  

If the pilot effectively dies, does that mean the end of “disease management” programs in traditional Medicare to better organize care for the chronically ill? CMS Spokesman Ashkenaz said no, noting that his agency is getting ready to launch a “medical home demonstration” in which doctors will be paid directly to better coordinate care of the chronically ill, rather than paying health care management firms to do so as is the case in the Medicare Health Support program. [Commonwealth Fund Washington Health Policy Week in Review; February 11, 2008] 

We welcome your point of view.

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