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Study shows difficulties in coordinating care

Medicare demonstration project

Study shows difficulties in coordinating care

Saving money and reducing hospitalizations in the chronic care population is difficult, but more in-person interaction could play a role in bringing about cost savings and improved outcomes, according to a recent study.

Researchers looked into the Medicare CoordinatedCare Demonstration (MCCD) project, which tested whether care coordination programs reduced hospitalizations, cut Medicare expenditures, and improved quality of care for chronically ill Medicare beneficiaries.

The review of 15 randomized trials showed that onlytwo were successful in reducing hospitalizations and one achieved sustainable cost savings.

Among the highlights of the study: Care coordination programs without a strong transitional care component probably won’t bring Medicare savings, and substantial in-person contact targeting moderate to severe patients can be cost-neutral and improve some aspects of care, according to Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries, which appeared in the February 11 Journal of the American Medical Association.

“Our results suggest that care coordination, as practiced by the programs participating in the demonstration from 2002 to 2006, holds little promise of reducing total Medicare expenditures for beneficiaries with chronic illnesses,” wrote the authors.

Randall Brown, PhD, director of health research at Mathematica Policy Research, Inc., in Princeton, NJ, and the study’s coauthor, says the results show that disease management (DM) programs with a call center–based foundation are not the right model for improving care for the chronically ill. This is because there isn’t enough collaboration between care coordinators, physicians, and patients or in-person contact for the classic DM model to be successful.

Brown says healthcare stakeholders are looking for a quick fix to the chronic illness problem, but reducing healthcare costs and improving patient outcomes is complicated and a call center–based approach doesn’t work.

“The encouraging thing is it can be done if you really look at the lessons we have learned over the past seven years of this study,” says Brown.

Jaan Sidorov, MD, MHSA, FAAP, an independent consultant who owns and operates Sidorov Health Solutions in Harrisburg, PA, and writes the “Disease Management Care Blog,” says the sobering results should not surprise the DM industry. Healthcare leaders continue to test care management approaches to see what can decrease costs and increase quality.

“For the right patient, it continues to make sense to rely on nurses that are available for in-person coaching, to use your predictive modeling algorithms to identify patients that are ‘high impact,’ to pursue medication adherence and persistence, to do everything possible to find and help patients that are recently discharged, and to build close relationships with the primary care physicians,” says Sidorov.

Demonstration tested high-risk beneficiaries

Through the MCCD, Medicare tested care coordination in the chronic disease population because half of the beneficiaries in 2002 were treated for five or more conditions, accounting for 75% of Medicare spending. Most of the costs were the result of hospital admissions and readmissions.

Studies have pointed to ways to effectively reach Medicare patients, such as patient-centered care, improving physician-patient communication, increasing patient adherence to recommended medications and self-care regimens, and making care more evidence-based. However, according to the authors of the MCCD study, “few relatively small, single-center trials of interventions that included some or all of these components have successfully lowered hospitalizations for Medicare patients.”

The 15 trials included fee-for-service Medicare beneficiaries, most of whom had congestive heart failure, coronary artery disease, and diabetes. (See Figure 1 on p. 3.)

Medicare paid providers a per month per member fee, and the program analyzed hospitalizations, costs, and quality-of-care outcomes.

Patients also completed a survey seven to 12 months after enrollment, which provided additional quality-of-care measures.

The interventions varied and included five commercial DM companies, three community hospitals, and three academic medical centers. All of the programs featured care coordinators (nurses) who provided patient education and monitoring, mostly via telephone, in hopes of improving adherence and communication with physicians. Nurses contacted patients twice per month on average. Among the interventions:

  • All but one program educated patients on improving adherence to medication, diet, exercise, and self-care regimens
  • Four programs focused on increasing physicians’ adherence to evidence- or guideline-based care
  • 14 sought to improve care coordination
  • 12 taught patients to communicate with their physicians more effectively
  • 10 programs provided timely information on the majority of patient hospitalizations or ED visits
  • Although the interventions varied in design, researchers found that the majority were simply not successful. Researchers discovered that:
  • Two of the 15 programs showed significant reductions in hospitalizations compared to the control group
  • None of the programs generated net savings
  • Three programs had monthly Medicare expenditures less than the control group by 9%–14%
  • No programs had favorable effects on the adherence measures, and only a few had a favorable effect on the quality-of-care indicators examined

“Despite these underwhelming results for care coordination interventions in general, the favorable findings for Mercy [Medical Center] and [Health Quality Partners (HQP)] suggest that the potential exists for care coordination interventions to be cost-neutral and to improve patients’ well-being,” the authors wrote.

Although the majority of interventions were not successful, the study’s authors did provide clues to why HQP and Mercy stood out:

  • The programs had more in-person interaction. The two interventions averaged nearly one in-person contact per month per patient. “Relatively frequent in-person contacts may be necessary to develop the level of trust that patients and their families need to consider the care coordinator an integral part of their care network and to confide in the coordinator and rely on his or her judgment,” the authors wrote.
  • The successful programs did not target patients who were low risk for hospitalizations or so seriously ill that interventions would not ward off hospitalization.
  • The two groups taught patients how to take their medications.
  • The care coordinators of the two groups worked closely with local hospitals, included timely information exchanges of hospitalizations, and worked to reduce readmissions.
  • Care coordinators in the two programs collaborated with physicians. For example, HQP allocated space at its site for care coordinators to meet with patients, and Mercy set up time at local clinics for patients to meet with care coordinators at the same time as their physician appointments.

The authors wrote that the results and other evidence from the literature suggest that the most effective care coordination interventions would be a model similar to the ones implemented by Mercy and HQP, coupled with a proven transitional care model to prevent hospital readmissions.

Given Mercy’s and HQP’s success, CMS has expanded those interventions for up to three more years, with the continuation depending on whether an interim evaluation—slated for 2010—shows “evidence of persistent favorable effects.”

Medical home

The sobering results of the MCCD may show that the medical home concept is a better way to improve care coordination, lower costs, and improve quality, the study authors wrote. The medical home could create close links between the patient’s care coordinator and physicians and allow for more in-person contact between the patient and care coordinator, leading to more timely information on hospital admissions.

“The successful interventions also may offer more detailed lessons for medical homes about how best to educate and monitor patients, the types of patients for whom they are likely to be most effective, and how to help patients overcome barriers to better self-care,” the authors wrote.

The MCCD study can also teach those interested in the medical home about the need for strong educational intervention and medication compliance, Brown says. Although the medical home concept has potential, medical homes must be targeted for at-risk patients. “If you don’t target people who are pretty high risk of hospitalization, then you’re going to spend a lot of money that won’t save you any hospitalizations, and that’s where the money is,” says Brown.

Sidorov questions the study authors’ conclusion that the medical home could work because there isn’t proof to reach that conclusion in the MCCD results.

“I personally think the pay dirt version will be provider-led care management that incorporates latest generation (telephonic) disease management and smart insurance benefit design and the right mix of physician reimbursement strategies,” says Sidorov, adding that patient registries, predictive modeling, and decision support will also play a role.

Although most of the interventions failed to control costs or reduce hospitalizations in the MCCD project, care coordination can work if designed properly, says Brown.

“The main thing is not to throw the baby out with the bathwater and conclude that nothing worked. Some did work,” says Brown. “It’s just that it’s not easy and it takes a well-designed program that is properly targeted if the goal is to save medical cost dollars. I think that’s true for both the commercial and Medicare population. That’s not to say that wellness and prevention programs aren’t a good idea for younger populations, but you’re looking for possible savings maybe years down the road and reductions in absenteeism and not reductions in hospitalizations for the most part.”