Don’t These Demonstrations Ever Work? Mixed Evidence from the Four-Year Medicare Coordinated

Care Demonstration

Introduction

AcademyHealth Annual ConferenceJune 9, 2008

Don’t These Demonstrations Ever Work? Mixed Evidence from the Four-Year Medicare Coordinated

Care Demonstration

Introduction

AcademyHealth Annual ConferenceJune 9, 2008

Linda MagnoDebbie PeikesArnold Chen

Jennifer SchoreRandy Brown

Linda MagnoDebbie PeikesArnold Chen

Jennifer SchoreRandy Brown

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RoadmapRoadmap

I. BackgroundII. Impacts on Service Use/CostIII. Impacts on Quality of CareIV. What Distinguishes Effective Programs V. Conclusions and Ongoing Work

I. BackgroundII. Impacts on Service Use/CostIII. Impacts on Quality of CareIV. What Distinguishes Effective Programs V. Conclusions and Ongoing Work

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BackgroundTheory Behind CC for Medicare FFS

BackgroundTheory Behind CC for Medicare FFS

Problem: Rapidly increasing Medicare costs

Chronically ill account for 75% of expenditures:– Half of beneficiaries have 1+ (of 8) conditions– 12% have 3+ and account for 1/3 of all costs

High rates of inpatient admissions– Many seem preventable– Often preceded by non-adherence, failure to

recognize warning signs

Patients see 5+ physicians per year

Problem: Rapidly increasing Medicare costs

Chronically ill account for 75% of expenditures:– Half of beneficiaries have 1+ (of 8) conditions– 12% have 3+ and account for 1/3 of all costs

High rates of inpatient admissions– Many seem preventable– Often preceded by non-adherence, failure to

recognize warning signs

Patients see 5+ physicians per year

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Causes of “Preventable” CostsCauses of “Preventable” Costs Difficulty adhering to drugs/diets/self-care advice

Care not always evidence-based

Some patients lack transportation, support services

Patients and providers communicate poorly:

– Patients don’t call soon enough or divulge fully– Providers don’t ensure patient understands– Providers don’t talk to each other (no incentives)– Typical advice if no appointments: “Go to the

ER”

Difficulty adhering to drugs/diets/self-care advice

Care not always evidence-based

Some patients lack transportation, support services

Patients and providers communicate poorly:

– Patients don’t call soon enough or divulge fully– Providers don’t ensure patient understands– Providers don’t talk to each other (no incentives)– Typical advice if no appointments: “Go to the

ER”

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The Promise of Coordinated CareThe Promise of Coordinated Care

A knowledgeable, accessible nurse coordinator

Increase adherence and access to services

Evidence-based guidelines Improve quality of care

Coordination of information Fill information gapsAvoid conflicting advice and errors

In-home monitoring Early detection/prevention

Good post-hospital care Reduce complications and readmissions

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Why Medicare Investigated CCWhy Medicare Investigated CC

Intuitive appeal

Potential to improve lives and reduce costs

Claims of huge effects in other markets

HMOs and employers are buying it:

– 1997: $78 million – 2000: $1.2 billion (2008: est. $1.8 billion)

Large, identifiable target population

Intuitive appeal

Potential to improve lives and reduce costs

Claims of huge effects in other markets

HMOs and employers are buying it:

– 1997: $78 million – 2000: $1.2 billion (2008: est. $1.8 billion)

Large, identifiable target population

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Extension/ExpansionExtension/Expansion

Secretary must extend/expand projects if initial evaluation (first 2 years) found – Savings– Budget neutrality plus improved quality

and beneficiary/provider satisfaction Secretary may, by regulation, incorporate

beneficial components of projects into Medicare program on permanent basis

Secretary must extend/expand projects if initial evaluation (first 2 years) found – Savings– Budget neutrality plus improved quality

and beneficiary/provider satisfaction Secretary may, by regulation, incorporate

beneficial components of projects into Medicare program on permanent basis

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CMS hoped to learn:

– Do the programs improve quality?

– Do the programs reduce gross cost?

– Are the programs budget-neutral?

–What program types/features work best?

–What types of patients do they work for?

CMS hoped to learn:

– Do the programs improve quality?

– Do the programs reduce gross cost?

– Are the programs budget-neutral?

–What program types/features work best?

–What types of patients do they work for?

Goals of the Demonstration

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The Demonstration ProgramsThe Demonstration Programs

15 were selected in January 2002

Wide variation in negotiated fees: $80 to $444 PMPM (average = $235)

Voluntary enrollment model

15 were selected in January 2002

Wide variation in negotiated fees: $80 to $444 PMPM (average = $235)

Voluntary enrollment model

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Program Hosts Represented a Variety of Organizations

Program Hosts Represented a Variety of Organizations

5 commercial CC/ DM providers

3 academic medical centers

4 hospitals/ integrated systems

Others: hospice, retirement community, long-term care facility

5 commercial CC/ DM providers

3 academic medical centers

4 hospitals/ integrated systems

Others: hospice, retirement community, long-term care facility

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Programs Served 16 States + D.C.Programs Served 16 States + D.C.

GeorgetownQMed

Hospice

Carle

CenVaNet

HQP

Charlestown

MCD

MercyAvera

Washington University

JHH

U of Md

Quality Oncology

CorSolutions

Hospice = Hospice of the Valley; HQP = Health Quality Partners; JHH = Jewish Home and Hospital Lifecare System; MCD = Medical Care Development; U of Md = University of Maryland.

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Nurses as Care CoordinatorsNurses as Care Coordinators

Staff were primarily registered nurses; most had cardiac or geriatric experience

Caseloads varied from 36 to 155; half were between 60 and 86

Program patients did not “graduate”

Most contact was by telephone

Staff were primarily registered nurses; most had cardiac or geriatric experience

Caseloads varied from 36 to 155; half were between 60 and 86

Program patients did not “graduate”

Most contact was by telephone

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Programs Varied Widely on Key Dimensions

Programs Varied Widely on Key Dimensions

Few had sophisticated IT or home telemonitoring 12 programs drew patients from physicians they had

experience with Programs focused on teaching patient about self

care and communication Service arrangement was not a focus Few had medication lists from providers Enrollment varied widely– 3 served 95 to 115– 9 served 415 to 725– 3 served 1,100 to 1,500

Few had sophisticated IT or home telemonitoring 12 programs drew patients from physicians they had

experience with Programs focused on teaching patient about self

care and communication Service arrangement was not a focus Few had medication lists from providers Enrollment varied widely– 3 served 95 to 115– 9 served 415 to 725– 3 served 1,100 to 1,500