Medicare Faces Challenges Caring for Chronically Ill

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That doesn't necessarily mean that ideas like these should be abandoned altogether, however.

Based on the findings, "we should not expect these care coordination efforts to pay for themselves or to save money," said Paul Precht, director for policy and communications at the Medicare Rights Center. "But that doesn't mean they're not worth doing, because when they work right, they can deliver better health for people."

And what makes them work right?

"If you target the programs well on people who have the right level of severity of illness and types of illnesses, and you have certain features, then you can have an impact on hospitalization rates. That's the key," said study senior author Randall Brown, vice president and director of health research at Mathematica Policy Research Inc. in Princeton, N.J. Mathematica designed this pilot project.

"The more that providers and particularly the physicians are directly involved and the more the physicians are part of an integrated network that includes the other specialties, the better [a particular program] works," added Precht.

The findings were published in the Feb. 11 issue of the Journal of the American Medical Association.

Most experts agree that exploding costs and the prospect of an empty purse threaten Medicare's future. According to an accompanying editorial, Medicare expenditures will top $400 billion this year, a hefty 13 percent of the total federal budget.

One study found that in 2002, about half of beneficiaries who had been treated for five or more conditions accounted for 75 percent of total spending.

Most of the costs associated with chronic illness come from hospital stays which, in turn, are often due to inadequate care between admissions (lack of counseling on improving lifestyle factors, lack of adherence to medication regimens, etc.).

One proposed solution is to better coordinate care between different physicians and other health care providers.

This complex analysis looked at 15 care-coordination programs involving more than 18,000 fee-for-service Medicare patients with chronic problems such as congestive heart failure, coronary artery disease and diabetes. Each program included between 178 and 2,657 patients. Care was assessed after individuals had been in the program at least seven months. The outcomes were then compared to those of a control group consisting of "usual care."

Only two of the 15 programs showed any significant difference in hospitalization rates, and one of those actually involved an increase of 0.118 admissions per person per year.

In one program, Mercy Medical Center in rural northwestern Iowa achieved 0.168 fewer admissions per person per year, 17 percent less than the control group.

Not one of the programs resulted in net savings, although three programs --- including Mercy and Health Quality Partners (HQP) in Pennsylvania -- did achieve some savings. HQP also had "close to significant effects on hospitalizations," Brown said.

The two success stories, Mercy and HQP, had certain features in common, namely more contact between nurse-coordinators and patients and more contact between coordinators and physicians.

"Both these programs had good relationships with local hospitals and with patients' physicians," Brown said. "The care coordinator knew the physicians, because they were either located in the same facility or the physicians set aside space for the care coordinator to interact with patients when the patients came in for a visit. They bumped into each other a lot."

Overall, however, the picture was not a positive one.

"It is discouraging. I think there's good reason to be skeptical of what these stand-alone disease-management companies can do," Precht said. "The record is mixed, but it's pretty clear, they don't save money."