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CMS: MHS did not save money or improve health

Second interim report

CMS: MHS did not save money or improve health

The second interim report of the Medicare Health Support (MHS) project was not what disease management (DM) hoped, but industry leaders say the analysis is not an indictment against the DM concept.

The Centers for Medicare & Medicaid Services (CMS) released the review of the first 18 months of the DM-inspired project to Congress shortly before the new year began.

The report found that DM programs did not save money, improve beneficiary self-management and physical and mental health functioning, or cut acute care utilization or mortality during the first half of the three-year project.

The second interim analysis found that none of the companies involved in the pilot reached the targets that would warrant program expansion.

The programs did not improve clinical quality of care and beneficiary satisfaction or achieve budget-neutral spending targets, according to CMS. (For a list of the companies included in the project, see “Medicare Health Support organizations” on p. 3.)

A CMS official says the interim findings show that in the first 18 months of the MHS project, DM was not successful in the Medicare fee-for-service (FFS) population.

Note: CMS policy does not permit public attribution of comments by its staff members.

“The first finding is that the approaches that have been used in commercial and the managed care populations, at least early on, have not achieved the same results in the Medicare fee-for-service population,” says the CMS official. “We haven’t found a lot that has really worked in terms of what’s worked and what hasn’t worked. The jury is still out until we see what happens in the end result.”

The CMS report, which Washington, DC–based RTI International prepared for the agency, provided the following key findings:

  • Several vulnerable subpopulations of Medicare FFS beneficiaries were less likely to participate in the MHS pilot
  • The DM companies’ interactions with participating beneficiaries are unlikely to produce significant behavioral change and savings
  • There was limited effect in improving beneficiary satisfaction, care experience, self-management, and physical and mental health functioning during the first 18 months of the project
  • Seven of the eight MHS organizations (MHSO) had a positive effect on one or more process-of-care measures, but no positive effect on reduction in acute care utilization or mortality
  • Fees accrued during the first 18 months far exceeded the savings produced

The CMS official says the MHSOs learned from the project and modified their offerings to better match the population during its course. “The different participants in the program have learned that they need to adapt to the needs and demographics in the Medicare fee-for-service,” the official says.

Although some may see the interim results as a judgment against DM’s nurse call center model, the results did not represent one particular care model. Instead, each of the eight MHSOs offered different programs, which were primarily call center–based, but some focused on physician outreach and face-to-face interactions with beneficiaries, the CMS official says.

The second MHS project report included deeper analysis that encompassed the project’s first six months, says Gordon K. Norman, MD, MBA, executive vice president for science and innovation at Alere, a DM company in Reno, NV, and chair of DMAA: The Care Continuum Alliance, which represents the DM/population health industry. However, the most recent analysis did not include the details of what did and didn’t work, which is what DM is interested in, he says.

Norman also questions CMS’ selection of Medicare beneficiaries who took part in MHS, many of whom were too sick or not sick enough to participate in a traditional DM program.

Health Dialog was one of the eight DM companies that participated in the MHS project, and one of the five that completed it. Christopher Coloian, senior vice president of health services at the Boston-based DM company, says the DM industry can learn from the MHS project, which is why Health Dialog stayed with it.

Coloian says he hopes healthcare leaders don’t view the interim report as the definitive study about DM’s effectiveness. DM has grown to a more than $2 billion business in commercial and Medicare Advantage populations because its customers know of the concept’s success in improving member health, he says.

“It would be a shame if folks took a very vibrant industry that we think is at the core of helping with medical cost management and quality improvements and really helpful in mitigating one of this country’s real concerns, which is the spiraling cost of healthcare, and put it through the sole lens of the Medicare Health Support finding,” says Coloian.

Key findings from second report

In analyzing the first half of the MHS project, RTI discovered that:

Several vulnerable subpopulations of Medicare FFS beneficiaries were less likely to participate in the MHS pilot. Although MHS was designed as a broad population-based FFS program, the participating populations were healthier, less costly, and used acute care services less than beneficiaries who did not participate in the program, RTI reported.

The interim review suggested that MHSOs’ recruitment strategies did not reach the most at-risk and sick populations, such as dual Medicare/Medicaid eligibles and beneficiaries with disabilities. In response, MHSOs said contacting costly beneficiaries was difficult because some were in nursing homes or other institutions and at the end of life when the project began.

The DM companies’ interactions with participating beneficiaries is unlikely to produce significant behavioral change and savings. In its report, RTI questioned MHSOs’ limited telephonic outreach. During the seven to 18-month time period, most beneficiaries received between two and five months of telephonic support, according to the report.

This limited outreach caused RTI to wonder whether the nurse call center model can work in the Medicare FFS population. “Given the lack of consistent monthly or bimonthly interaction with many of the MHS participants, it is unlikely that the MHSOs will be successful at changing beneficiary behavior with respect to self-management of their chronic illness,” wrote RTI.

RTI also found that beneficiaries who were surveyed did not experience “meaningful improvements” in the area of self-care activities. In fact, of the 27 gauged beneficiary survey measures, 13% showed significant positive intervention and 2% alleged negative intervention effect.

The remaining indicators were not statistically different between the intervention and comparison beneficiaries.

MHSOs achieved success helping beneficiaries set goals to address their care needs, but there was little improvement in self-efficacy or self-care activities. The combination of limited calls to beneficiaries coupled with self-care behaviors not improving 18 months into the project caused RTI to state that the MHS project will not significantly improve behavior.

“To positively affect acute care utilization, one would expect to see improvement in self-care behaviors by the midway point of the pilot, and savings have proven illusive to date,” wrote RTI.

There was limited effect in improving care experience, beneficiary satisfaction, self-management, and physical and mental health functioning during the first 18 months of the project. RTI reported that only two of the MHSOs, Health Dialog and Aetna, improved beneficiary satisfaction, which gauged how well a company was helping beneficiaries cope with their chronic condition.

In addition, none of the MHSOs “demonstrated consistent positive intervention effects across the four domains of satisfaction, care experience, self-management activities, and physical and mental health functions,” according to the 18-month interim report.

The MHS authorizing legislation stated that the organizations needed to improve quality of care and beneficiary satisfaction and achieve savings targets so CMS could expand the pilot. The organizations did not achieve those goals in the first 18 months, RTI wrote.

“The focus of the pilot program interventions was largely on impacting beneficiary behavior to better manage their chronic illness,” wrote RTI in its review. “Yet these results show little evidence of changes in self-efficacy or self-care. We did not observe any consistent pattern of positive intervention effects by disease cohort of heart disease only, diabetes only, and heart failure and diabetes.”

Seven of the MHSOs had a positive effect on one or more process-of-care measures, but no positive effect on reduction in acute care utilization or mortality. To achieve quality improvement measures and improve health outcomes, MHSOs needed to increase rate of receipt of claims-based process-of-care measures and improve health outcomes by reducing hospitalizations, readmissions, ER visits, and mortality rates relative to their comparison group.

One of the provisions of the MHS legislation was that the project improve quality and health outcomes. RTI tested five quality measures and found that only 40% of the measures were achieved in the patient population. Seven of the MHSOs demonstrated at least one positive intervention effect, but the rates of improvement in the quality-of-care measures were only 2 to 4 percentage points.

None of the organizations demonstrated positive intervention effects related to health outcomes. RTI found no reduction in mortality rates or time to death during the first 18 months of the pilot.

Fees accrued during the first 18 months far exceeded the savings produced. The third requirement for program expansion was financial savings defined as budget neutrality when factoring in MHSOs’ accrued management fees.

At the MHS project’s halfway point, RTI said none of the MHSOs achieved gross savings. Savings at the halfway mark offset 12%–26% of estimated accrued fees for four of the MHSOs, with the remaining showing no evidence of savings.

“The four MHSOs with modest savings would have to increase their rate of savings by roughly three- to sevenfold, while the second group of four nonsavers has a significantly higher hurdle,” according to the second interim report. “This seems unlikely given performance over the first 18 months.”

The five findings create a fairly negative view of the MHS project. “Given the limited gains regarding quality of care and savings to offset accrued monthly management fees, it will be difficult to justify these private disease management models on cost effectiveness grounds—at least for chronically ill Medicare FFS beneficiaries,” wrote RTI in its analysis to CMS.

Two years away from third report

The CMS official says the third report for the MHS project will provide the findings for the whole three-year project. That analysis is expected in February 2011, although the official says CMS will release the findings sooner, if possible.

For the final report, Norman says he would like to see which programs worked and which did not so the DM/ population health industry can learn from the experience. The analysts should not only compare programs, but delve deeper to find the results from subgroups, such as those with dementia and depression, he says.

“I think that’s how you tease out the combination of factors that may explain the totality of the results … I am very hopeful that the final report that looks back over the whole three-year experience does a better job of probing into areas that will maximize our learning from this very large, very expensive trial,” Norman says.

The CMS official says the interim report highlighted some subpopulation comparisons, such as heart failure beneficiaries versus those with diabetes, but the researchers didn’t find much difference between the results. If CMS and RTI don’t provide the level of detail that allows the DM/population health industry to learn which programs worked and which did not, Norman says he hopes CMS provides the data to a third party to analyze.

“We can ill afford to reject looking at any promising solution just as we can ill afford to throw out any favorable baby with the undesirable bathwater from MHS,” says Norman. “There has to be some valuable learnings hidden by this sort of blanket up or down evaluation bias that I think has been portrayed in the first two reports.”

The ultimate message from the MHS project is the difficulty of intervening with the Medicare FFS population, says Norman. One reason is that, unlike Medicare Advantage, many FFS beneficiaries don’t have primary care physicians.

Is this the end of DM Medicare projects?

Despite the MHS project’s negative interim results, CMS will continue to test DM programs. DM/population health elements are evident in other demonstration projects.

For example, LifeMasters Supported SelfCare, Inc., has been working on a successful demonstration project in Florida that is being offered to beneficiaries who are dual-eligible for Medicare and Medicaid and have congestive heart failure (CHF) or a combination of CHF, diabetes, and coronary artery disease.

The Medicare Medical Home Demonstration that is scheduled to begin in 2010 could include a DM/population health element.

Patients need the various elements of healthcare working together to create a better system, Norman says, adding that one area of healthcare can’t do it alone.

“I don’t think either party working alone can optimize population health outcomes,” says Norman. “That’s obviously a bias I have, and it may or may not be shared in the provider community, but it would be a shame to see magic-bullet attempts on the provider side to go through the same learning curve as DM over the last 15 years only to realize that we need to converge and integrate our respective roles and capabilities in order to maximize the outcomes.”

Coloian says he hopes CMS and the DM industry take what they learned from the MHS project and forge ahead with another DM pilot because MHSOs better understand the Medicare FFS population.

“It is incumbent upon Medicare and the industry to really learn not only about the first 18 months, but the entire 36 months, and look for the next opportunity,” says Coloian.

Tale of MHS

The Centers for Medicare & Medicaid Services (CMS) kicked off the Medicare Health Support (MHS) project in 2005 as a way to test the effectiveness of disease management (DM) programs in the Medicare fee-for-service (FFS) population for heart failure and diabetes beneficiaries. CMS selected eight organizations to take part in the first care management project in the Medicare FFS population. The DM companies focused on eight geographic areas and supplemented the care of about 287,000 chronically ill Medicare beneficiaries.

Before long, companies involved in the project began raising concerns, and three MHS organizations (MHSO) ultimately dropped out before the project’s completion. The organizations that dropped out complained that the patient population wasn’t as sick as expected, the initial 5% savings requirement was too ambitious, and CMS’ collaboration and transparency were lacking.

After a disappointing first interim report, CMS decided to end Phase I of the MHS project with no plans for a Phase II. The news was met with much consternation from the DM/population health industry and caused many to wonder about the effectiveness of DM programs. The announcement also affected one of the MHSOs—Healthways—which saw its stock drop after the announcement.

Industry leaders petitioned Congress and the Senate to push for a Phase II, but the MHS project ended quietly in 2008 without talk of reauthorization.

Those involved with MHSOs and DM leaders have raised several questions about the project, such as the composition of the target group (claiming DM could not effectively help those who were near death and those who were healthy but living with a chronic disease), the lag time in CMS getting current claims data to the MHSOs, and the lack of timely updates provided by CMS so the DM industry could learn from the project.

The final report that will analyze all three years of the MHS project is expected in February 2011.

Medicare Health Support organizations

Organization Target geography End date

Healthways Maryland and Washington, DC July 31, 2008

LifeMasters Supported SelfCare Oklahoma December 31, 2006

Health Dialog Services Corp. Western Pennsylvania August 14, 2008

McKesson Health Solutions, LLC Mississippi May 31, 2007

Aetna Life Insurance Co. Chicago (surrounding area) August 31, 2008

CIGNA Health Support Northern Georgia January 14, 2008

Green Ribbon Health West-central Florida August 15, 2008

XL Health Corp. Tennessee (selected counties) July 31, 2008

Source: Centers for Medicare & Medicaid Services.