Dear Senator Isakson and Warner

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January 26th 2016

The Honorable Johnny IsaksonThe Honorable Mark Warner
United States SenateUnited States Senate
131 Russell Senate Office Building475 Russell Senate Office Building
Washington, DC 20510Washington, DC 20510

Dear Senator Isakson and Warner:

The Case Management Society of America (CMSA) appreciates the opportunity to comment on the Senate Finance Chronic Care Working Group’s document which outlines policy options for improving the care and treatment of Medicare beneficiaries living with multiple chronic conditions. CMSA supports and promotes that care coordination is key to supporting Medicare beneficiaries and their family caregivers in working with and managing their chronic illness.

CMSA is an international non-profit 501(c) (6) multi-disciplinary professional association established in 1990,and we are is dedicated to the support and advancement of the case management profession through educational forums, networking opportunities, legislative advocacy, and establishing standards to advance the profession. The association is based in Little Rock, AR, with a public policy office in Washington DC, serving more than 30,000 members/participants and 75 affiliate chapters. Since its inception, CMSA has been at the forefront of setting professional standards for the industry, which allows for the highest level of efficiency and integrity, as well as developing national and local leaders who are recognized for their practice and professional excellence. Professional case managers are recognized experts and vital participants in the care coordination team and they work closely with chronic care patients and families throughout the healthcare continuum

CMSA supports your goals to “increase care coordination among individual providers across care settings who are treating patients living with chronic disease.” As you are aware, patients face significant challenges when moving from one care setting to another within our fragmented health care system. Poor communication during transitions can lead to confusion about the patient’s condition and appropriate care, duplicative tests, inconsistent patient monitoring, medication errors, and lack of follow through on referrals. Navigating these transitions can be even more difficult for individuals with a serious illness who may be too frail to communicate effectively for themselves and rely heavily on their care team and family caregivers. Furthermore, given the nature of their illness, patients may have multiple providers and will move between different care settings more often, putting these medically complex patients at higher risk for gaps in care due to improper communication between providers and other caregivers. These breakdowns create serious patient safety, quality of care, and health outcome concerns.

CMSA Support the Proposed High-Severity CCM Code and the CCM Copay Wavier

CMSA supports adding a new high-severity chronic care management (CCM) code that clinicians could bill under the Physician Fee Schedule. Patients with multiple chronic conditions require the coordination of team-based care. The patient population requiring increased levels of interaction with the clinical team most often present with 5 or more chronic conditions, may be “frail elderly”, patients with Alzheimer’s or a related dementia and in many cases impaired functional status. There are also multiple non-clinical issues that contribute to the need for interventions from the team; such as the patient lives alone and has no caregiver, low health literacy, language barriers, lack of transportation and financial concerns. CMSA encourages the Chronic Care Working Group to consider using clinical and non-clinical patient criteria for determining eligible beneficiaries.

CMSA supports advancing team-based care and would ask that the Chronic Care Working Group include the professional case manager (registered nurses and social workers) who have advanced training and certification to provide the scope of services proposed in the CCM codes. The medically complex patient often requires a higher intensity of service such as:

• A comprehensive assessment of the individual including the physical and mental health conditions, cognitive and functional capacities, medication regime and adherence, social and environmental needs, and primary caregiver needs and resources
• Development of a comprehensive evidenced based plan of care developed with the patient, family and primary care provider
• Development of a comprehensive medication plan that ensures safe use and understanding of their medication plan by the patient and family.
• Assessment and coordination of care with multiple providers of care for the individual
• Assessment of the individual and family health literacy to enhance communication
• Individual and family education and support for treatment and medication adherence
• Coordination with the individual and providers to ensure consistency of treatment plan and communication to avoid adverse outcomes

Clinical staff providing these services (even under the supervision of a physician), must be able to conduct an independent assessment of the patient and family. As such it must be provided by licensed professional clinical staff that are qualified to conduct that independent assessment. CMSA encourages the Working Groupto go even further and consider attribution of payment for the professional case manager directly participating in collaborative team-based and integrated practice models of care.

CMSA supports the Working Group’s proposal to waive the co-payment associated with the current care management (CCM) code. Care management has been proven to reduce costs and readmissions, but for patients on limited income, this copay can be a barrier to receiving care that many beneficiaries believe should be free in receiving proper care. CMSA has heard from case managers that many of their Medicare patients refuse the service because of the copay expectation.

Addressing the Need for Behavioral Health Integration for Chronically Ill Beneficiaries

CMSA commends and supports the Chronic Care Working Group’s proposal to improve care for patients living with chronic disease and behavioral health disorders. Patients with chronic medical illnesses have been found to have two to threefold higher rates of major depression compared with other primary care patients[i]. The association between the two can be attributed to depression expediting chronic disease which, in turn, exacerbates symptoms of depression. It is estimated that up to one third of individuals with a serious medical condition experience symptoms of depression.[ii] Continuing to confront any current stigma around mental health care is an important part of chronic care management. It is also important that all types of providers are able to talk with one another to help create a full care plan with the patient and family caregiver.

CMSA provides advanced training for case managers and allied health professionals supporting beneficiaries with integrated care needs through the CMSA Integrated Case Management delivery model. CMSA supportsimproved parity between behavioral health and physical health. For this complicated population with multiple chronic medical and behavioral concerns, providers must be able to treat the patient as a whole and coordinate the beneficiary’s care as a team.

CMSA Supports the Authorization of Medication Adherence Study

CMSA supports the Working Group’s proposal to authorize a study that will improve medication adherence. Medication non-adherence is a multifaceted problem, especially for patients with chronic conditions. Numerous studies have shown that medicines improve the clinical out-comes of morbidity and mortality. Despite such findings, many patients do not realize the full potential benefits of prescription therapies. All too often this situation is the result of their failure to take some or all of the medications prescribed by the physician. The consequence is a decrease in quality-of-life improvement derived from medicines and unnecessary increases in avoidable healthcare utilization and costs. Approximately one-third of all hospital readmission are attributed to medication adherence issues.iii

Adherence is a complex behavioral process strongly influenced by the environments in which patients live, healthcare providers practice, and healthcare systems delivery of care. It is related to the way in which a patient judges personal need for a medication against a variety of competing needs, wants, and concerns (adverse effects, stigma, cultural beliefs, costs, etc.). In fact, patients are not the only factor that affects adherence. Healthcare providers, complex medication regimes, medical complexity, care coordination, transitions of care planning, information transfer and accessing and navigating the healthcare delivery system can contribute to the problem of nonadherence.

CMSA encourages the Working Group to ensure the study not only analyzes medication reconciliation but to include increasing the use the Part D Comprehensive Medication Review more extensively and including both clinical and non-clinical (humanistic) concerns to ensure a ‘Best Practice” is developed in addressing the concerns of improved medication adherence.

CMSA has developed a comprehensive approach to addressing issues related to adherence to chronic therapies, the Case Management Adherence Guidelines (CMAG). CMAG was developed from concepts presented by the World Health Organization to aid in the assessment, planning, facilitation and advocacy for patient adherence supported through case management and population health initiatives. The guidelines provide an interaction and management algorithm to assess and improve the patient’s knowledge and his or her motivation to take medications as they are prescribed. The guidelines provide great flexibility in that individual patient needs can and preferences are taken into account. To date over 500,000 copies of the Case Management Adherence Guidelines have been downloaded off the CMSA website

Expanding Innovation and Technology

CMSA supports the use of telehealth and remote monitoring which can enhance the ability of the team to provide virtual and timely care coordination. It is imperative that those services be aligned with payment, interoperability, outcomes, qualified professionals and the issues of multistate licensure requirements.

The need and ability to use telehealth should be available to all Medicare beneficiaries whether in a MA, ACO, MSSP or government program. For those beneficiaries living in rural communities this alternative mode of care delivery could have a major impact on reducing avoidable hospital readmissions and non-adherence to treatment and medication plans.

CMSA appreciates the opportunity to submit these comments and looks forward to working with the Chronic Care Working Group to improve patient outcomes and strengthen our health care delivery system. Please contact Cheri Lattimer, executive director CMSA at for further discussion or information.

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Sincerely,

Cheri LattimerKathleen Fraser RN-BC, MSN, MHA, CCM, CRRN

Executive Director CMSA President

Patricia Noonan RN, MBA, CCM

CMSA Public Policy Committee Chair

Positively impacting and improving patient wellbeing and health care outcomes.
Case Management Society of America | 301 Ranch Drive | Little Rock, AR 72223 T 501.225.2229 F 501.221.9068 E

[i] Katon W. Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues in Clinical Neuroscience. 2011; 12(1): 7-23. Available here:

[ii] Dailey S, Gill C, Karl S Barrio Minton C. DSM-5 Learning Companion for Counselors. Alexandria, VA: American Counseling Association; 2014.

iii CMSA, CMAG 2012