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«June 22, 2015 601 Pennsylvania Avenue, NW VIA ELECTRONIC SUBMISSION TO Suite 835, South Building ...»

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David Schwartz

Head of Global Policy

Cigna Federal Affairs

June 22, 2015

601 Pennsylvania Avenue, NW

VIA ELECTRONIC SUBMISSION TO http://www.chronic_care@finance.senate.gov

Suite 835, South Building

Washington, DC 20004

(202) 719-6499

The Honorable Johnny Isakson David.Schwartz@Cigna.com

United States Senate

131 Russell Senate Office Building

Washington, DC 20510

The Honorable Mark Warner

United States Senate 475 Russell Senate Office Building Washington, DC 20510

Dear Senators Isakson and Warner:

Cigna welcomes the opportunity to offer ideas and insights in response to the Senate Finance Committee’s request for stakeholder input on improving care for chronically ill beneficiaries throughout the Medicare program. We appreciate the Committee’s efforts to improve the health and well-being of the Medicare population, and believe that our experience in bringing high quality care coordination, management, and health outcomes to almost 500,000 enrollees in our Medicare Advantage plans, many of whom have one or more chronic conditions, makes our insights on how to bring these ideas to beneficiaries in the fee-for-service (FFS) program especially relevant.

Cigna Corporation, together with its subsidiaries (either individually or collectively referred to as “Cigna”), is a global health services organization dedicated to helping people improve their health, well-being and sense of security. Our subsidiaries are major providers of medical, dental, disability, life and accident insurance and related products and services. Worldwide, we offer peace of mind and a sense of security to our customers seeking protection for themselves and their families at critical points in their lives.

We serve over two million Medicare and Medicaid beneficiaries through our MA, Part D, Medicare Supplemental, and Medicaid offerings. Our focus on this market has allowed us to develop a unique approach to healthcare coverage for beneficiaries, many of whom live with chronic conditions. We have a deep understanding of the needs and challenges facing both patients and physicians, and thus have developed a collaborative model that provides more access to high quality care for our customers while supplying physicians what they need to deliver that care.

“Cigna” is a registered service mark, and, “the ’Tree of Life’” logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc David Schwartz June 22, 2015 Page 2 Our suggestions for improving care for Medicare patients with chronic conditions in the Medicare Advantage and FFS programs are outlined below. We would be happy to provide any additional information or perspectives that would be helpful to you. Please let me know how Cigna can assist you in this important work.

Thank you for your consideration of these comments.

Respectfully, David Schwartz cc: Senator Orrin Hatch Senator Ron Wyden David Schwartz June 22, 2015 Page 3 Chronic Care in Medicare Advantage While we believe that there are opportunities to bring greater care management for chronically ill beneficiaries to the FFS Medicare program, we know the opportunity for high quality chronic care and the promise of better health outcomes for patients with chronic illness exists in the Medicare Advantage (MA) program today.

Medicare Advantage plans offer benefits and services that are designed specifically for those with chronic

illness, including:

• Case management services

• Disease management programs

• Coordinated care programs

• Prescription drug managements tooled integrated with medical benefits

• Nurse help hotlines

• Enhanced coverage of home infusion, personal care, and durable medical equipment.

Given the proven effectiveness of MA in delivering better care and outcomes for chronically ill members, the challenge becomes how to create the right incentives for beneficiaries who have chronic illnesses to enroll in MA, and how to ensure that MA plans have the right incentives to serve these beneficiaries.

Bringing Chronic Care to Dual-Eligible and Low-Income Chronically Ill Members:

The second challenge, of ensuring that MA plans are able to serve the chronically ill, requires recognizing the unique barriers that plans face when they serve these members, and adjusting the existing payment and quality rating systems to recognize added costs and barriers that come with serving the sickest and most vulnerable beneficiaries.

Both our own experience and external research clearly show that the burden of chronic illness falls heavily on beneficiaries who are dual-eligibles – those who qualify for both Medicare and Medicaid benefits. Recent data suggest that about one-third of dual-eligibles have diabetes, more than half have high blood pressure, and up to a third have chronic heart disease. Chronic cognitive and behavioral health conditions also affect the dualeligible population: 23 percent of dual-eligibles age 65 and older suffer from Alzheimer’s disease or related dementia, 20 percent suffer from depression, and 11 percent have anxiety disorders (Medicare Payment Advisory Commission and Medicaid and CHIP Payment and Access Commission, January 2015). As these statistics demonstrate, the care management that MA provides is especially critical for dual-eligibles.

Over 30 percent of Cigna-HealthSpring’s MA members currently are dually eligible for both Medicare and Medicaid benefits and services, compared with about 18 percent of the MA population overall. While the majority of our dual members (66 percent) are enrolled in special needs plans (SNPs) specifically designed to address their needs and that assist members with accessing and coordinating benefits across programs, a significant number of dual-eligible members choose to enroll in our regular MA offerings.

Dual-eligible beneficiaries, out of all our beneficiaries, derive the greatest benefit in terms of quality health outcomes – and improved quality of life – from the coordinated care that our MA plans provide. Research consistently shows that patients with chronic illness who are enrolled in MA receive more effective and appropriate care, have fewer hospitalizations and hospital days, and have a lower rate of complications than similar patients in the FFS program. 1, 2, 3, 4.

1 Cohen, R, et. al., “Medicare Advantage Chronic Special Needs Plan Boosted Primary care, Reduced Hospital Use Among Diabetes Patients” Health Affairs, 31, no.1 (2012):110-119.

David Schwartz June 22, 2015 Page 4 Our decades of work on behalf of Medicare beneficiaries show that achieving high-quality health care and better outcomes for members with chronic illness is a team effort involving the health plan, providers, and patients.

Our experience at Cigna-HealthSpring clearly demonstrates that dual-eligible beneficiaries have a more difficult time achieving desired quality health outcomes, such as screenings and preventive services, adhering to prescribed medication regimens, or following through with basic treatment recommendations. Sociodemographic factors, such as language barriers, nutrition, and housing, play a key role in keeping some members from achieving better outcomes, despite having access to the same providers, services, and benefits as all members. For example, low-income members may not follow through on recommended screenings or preventive care, or may have difficulty with medication adherence, because they lack access to transportation.

Our dual-eligible population requires tremendous investment in resources such as social workers, behavioral health specialists, nurse practitioners, in-clinic pharmacists, and other physician extenders to address the medical and social issues that often keep dual members from achieving the same health care goals and outcomes as other members. Ensuring that prescriptions are filled, medications are taken as prescribed, screening appointments are kept, and diagnostic tests are performed often means adding additional benefits such as transportation services, social workers, pharmacists, or advanced care nurses to supplement the traditional care teams that typically meet the needs of non-dual patients.

Unfortunately it is becoming more difficult to continue bringing the benefits of greater chronic care and intensive services to the dual-eligible population. Because the Stars Quality Rating System for MA plans fails to recognize differences in the population that plans serve, it results in biased ratings that in turn reduce payments (higher benchmarks and rebates that accompany higher Star ratings) to plans that serve a larger share of dualeligible and low income members. These reduced payments lead to reduced benefits and services in plans serving such members, and threatens access for these populations.

CMS, along with other key groups such as the National Quality Forum and MedPAC acknowledge the disparity in Star ratings and are studying potential ways to address the problem. In the interim, a coalition of MA plans that serve a disproportionate share of dual-eligible and low-income members has developed a short-term proposal to correct the disparity using information about a plan’s share of dual-eligible and low-income members and its demonstrated efforts to improve chronic and preventive care for its members.

We believe that an immediate, short-term solution is required to protect access to plans that serve a large share of dual-eligible and low-income chronically ill members. Until a long-term structural solution is developed, this short-term approach must hold plans accountable for providing high quality coverage, while recognizing the outsized challenges that increase as a plan’s share of low-income membership increases up the continuum.

Under our suggested proposal, plans would be eligible to earn an adjustment to compensate for the structural bias in the Star Ratings against plans serving low income members. The eligibility for and amount of the adjustment would be based on a contract’s statistically significant improvement on the subset of measures and the contract’s share of low-SES membership. The adjustment would apply to a plans’ Overall Star Rating as well 2 Landon, BE, et. al., “Analysis Of Medicare Advantage HMOs Compared With Traditional Medicare Shows Lower Use Of Many Services During 2003 -09.” Health Affairs, 31, no.12 (2012):2609-2617.

3 Kaplan, J, et. al. “Alternative Payer Models Show Improved Health Care Value.” May 2013, Boston Consulting Group.

Lemieux, J, et. al. “Hospital Readmission Rates in Medicare Advantage Plans.” Am J Manag Care. 2012;18(2):96-104 4 David Schwartz June 22, 2015 Page 5 as its Part C and D Summary scores, as shown in Table 5. We would be happy to provide additional information about the proposal to the Committee.

–  –  –

Value-Based Insurance Design:

Value Based Insurance Design (VBID) that incentivizes beneficiaries through cost-sharing and benefit design to use high-quality/lower cost providers and allows incentives for participation in healthy activities would reduce costs and increase quality. Allowing 'non-Medicare' benefits to be offered as part of a coordinated care plan would improve overall care and outcomes.

David Schwartz June 22, 2015 Page 6 An example of a cost-sharing benefit design that could be considered includes the ability to waive or reduce cost-sharing requirements when a beneficiary is participating in an intense care plan that involves frequent physician interventions. Intensive chronic management care plans may entail daily or weekly provider visits for a period of time. Requiring that the beneficiary be responsible for the applicable PCP or office visit coinsurance is a financial deterrent to following the care plan. Having the ability to selectively waive coinsurance requirements for beneficiaries participating in such coordinated care programs will increase compliance. In order to ensure adequate beneficiary protection, MA-PD plans should submit their decision-making process and criteria for CMS review and be prepared for CMS audit of activities.

Another example would be a cost-share differential if the beneficiary will agree to use providers that have proven high-value outcomes in treating chronic conditions. Ensuring beneficiary access to care with a reasonable number of options and within reasonable traveling distance is imperative, but the ability to have a tiered network design that offered greater benefits and incentives for beneficiaries to use high-value providers would result in better care delivery and quality outcomes. MA-PD plans should be allowed to tier their network within a PBP, but the criteria for provider inclusion in each network tier should be open to CMS review and made transparent to beneficiaries. This could be accomplished through designation of high-value providers in directories, educational materials explaining why a provider is designated high-value, and transparency around quality outcomes.

Examples of incentives for participation in healthy activities include monetary rewards or other items of value for closing gaps in care, participating in wellness services or completing some physical activity goals. The current limit of $15 per member per year value for any incentives is not sufficient to impact beneficiary behavior.

Incentives need not be exclusively cash rewards, but may include reduced coinsurance requirements, food coupons, or reward items generally considered of interest to the beneficiary population such as canes, home assistance items, and alert devices. A rewards program could be implemented and administered by a third party, with eligibility for the reward provided by the MA-PD plan as encounter data documenting participation in the desired activity is recorded. Identified activities and corresponding rewards should be open to CMS review.

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