1. 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 Linda Magno Debbie Peikes Arnold Chen Jennifer Schore Randy Brown

2. 1 Roadmap I.Background II.Impacts on Service Use/Cost III.Impacts on Quality of Care IV.What Distinguishes Effective Programs V.Conclusions and Ongoing Work I.Background II.Impacts on Service Use/Cost III.Impacts on Quality of Care IV.What Distinguishes Effective Programs V.Conclusions and Ongoing Work

3. 2 Background Theory 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

4. 3 Causes 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”

5. 4 The 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 gaps Avoid conflicting advice and errors In-home monitoring  Early detection/prevention Good post-hospital care  Reduce complications and readmissions

6. 5 Why 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

7. 6 Extension/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

8. 7 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

9. 8 The 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

10. 9 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

11. 10 Programs Served 16 States + D.C. Georgetown QMed Hospice Carle CenVaNet HQP Charlestown MCD Mercy Avera 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.

12. 11 Nurses 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

13. 12 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