Linda Magno Debbie Peikes Arnold Chen Jennifer Schore Randy Brown
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Don’t These Demonstrations Ever Work? Mixed Evidence from the Four-Year Medicare Coordinated Care Demonstration Introduction AcademyHealth Annual Conference June 9, 2008 Linda Magno Debbie Peikes Arnold Chen Jennifer Schore Randy Brown
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Don’t These Demonstrations Ever Work? Mixed Evidence from the Four-Year Medicare Coordinated Care Demonstration Introduction AcademyHealth Annual Conference June 9, 2008. Linda Magno Debbie Peikes Arnold Chen Jennifer Schore Randy Brown. Roadmap. Background Impacts on Service Use/Cost - PowerPoint PPT Presentation
Transcript of Linda Magno Debbie Peikes Arnold Chen Jennifer Schore Randy Brown
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
