Feb 10 2009
Only 2 of 15 Medicare programs designed to improve care and costs for patients with chronic illnesses resulted in reduced hospital admissions, and none of the programs generated net savings, according to a study in the February 11 issue of JAMA.
Chronic illnesses pose a significant expense to the Medicare program. The high expenditures generated by these beneficiaries are driven primarily by hospital admissions and readmissions, according to background information in the article. Several factors appear to contribute to the high rate of hospitalizations, including patients receiving inadequate counseling on diet, medication, and self-care; not having ready access to medical help other than the emergency department; and poor communication betweens patients and physicians. Some studies have suggested that interventions to address the barriers faced by chronically ill patients could reduce avoidable hospitalizations and decrease Medicare expenditures.
To study whether care coordination improves the quality of care and reduces Medicare expenditures, the Centers for Medicare & Medicaid Services (CMS) in 2002 competitively awarded 15 demonstration programs to various health care programs. Deborah Peikes, Ph.D., and colleagues from the Mathematica Policy Research Inc., Princeton, N.J., analyzed the results from randomized controlled trials of these 15 programs on how they affected Medicare expenditures and quality of care. The programs included eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 and were randomly assigned to treatment or control (usual care).
Hospitalizations, Medicare expenditures and some quality-of-care outcomes were measured with claims data for 18,309 patients (n = 178 to 2,657 per program) from patients' enrollment through June 2006. A patient survey 7 to 12 months after enrollment provided additional quality-of-care measures. Nurses provided patient education and monitoring (mostly via telephone) to improve the ability to communicate with physicians and adherence to medication, diet, exercise and self-care regimens. Patients were contacted twice per month on average; frequency varied widely.
The researchers found that 13 of the 15 programs showed no significant differences in hospitalizations. Mercy Medical Center, in northwestern Iowa, significantly reduced hospitalizations by 17 percent, and Charlestown retirement community in Maryland had an increase of 19 percent more hospitalizations.
None of the programs reduced regular Medicare expenditures. Treatment group members in 3 programs (Health Quality Partners [HQP, in Pa.], Georgetown, [a medical center in Washington, D.C.] and Mercy) had monthly Medicare expenditures less than the control group by 9 percent to 14 percent. Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. For total Medicare expenditures including program fees, the treatment groups for 9 programs had 8 percent to 41 percent higher total expenditures than the control groups did, all statistically significant.
For the survey-based outcomes-of-care measures, despite reporting much higher rates of being taught self-management skills, treatment group members were no more likely than control group members to say they understood proper diet and exercise, or to state that they were adhering to prescribed or recommended diet, exercise, and medications.
The authors add that a comparison of the two programs with the most positive results with the other programs indicates there were a number of noteworthy differences, including higher rates of in-person contact per month per patient; treatment group members were significantly more likely than control group members to report being taught how to take their medications; care coordinators for both HQP and Mercy worked closely with local hospitals, which provided the programs with timely information on patient hospitalizations and improved their potential to manage transitions and reduce short-term readmissions; and care coordinators in both programs had frequent opportunities to interact informally with physicians.
"Despite these underwhelming results for care coordination interventions in general, the favorable findings for Mercy and HQP suggest that the potential exists for care coordination interventions to be cost-neutral and to improve patients' well-being," the researchers write.
Editorial: The Elusive Quest for Quality and Cost Savings in the Medicare Program
John Z. Ayanian, M.D., M.P.P., of Brigham and Women's Hospital and Harvard Medical School, Boston, writes in an accompanying editorial that despite these findings, this study offers two important insights to guide Medicare policy on coordination of chronic disease care going forward.
"First, care coordinators must interact in person with patients and not simply educate or assist them by telephone. Only 4 of the 15 programs emphasized in-person contact between coordinators and participants, including both of the programs that CMS allowed to continue."
"A second crucial lesson is that care coordinators must collaborate closely with patients' physicians to have a reasonable prospect of influencing care. Only 4 of the 15 programs had coordinators who were based in physicians' offices or who attended patients' medical appointments, including both of the programs that were authorized by CMS to continue."
Watchdog calls for tighter scrutiny of Medicare Advantage home visits