Medical Homes and care coordination are tested

Older Americans who, understandably, have more chronic conditions of aging, are sadly also blamed for accounting for “disproportionately” large amounts of Medicare spending. It is sometimes thought that the increased services those suffering from chronic conditions require could be due to inadequate counseling on diet, medication, and self-care or not having ready access to medical care.

As the authors of a new study wrote, it’s often believed that patients “lack the knowledge and skills to understand how to manage their conditions or have barriers that prevent them from adhering to their doctor’s advice and prescriptions.” That’s been the thinking behind “coordination of care” and disease management programs provided by Medicare and other health plans (sometimes contracted out to commercial disease management vendors). In these programs, nurses provide patient education and monitoring (mostly telephonic) to improve adherence to medication, diet, exercise and self-care regimens.

Few trials of these interventions have successfully lowered hospitalizations for Medicare patients, however, the study authors noted. “To study whether care coordination improves the quality of care and reduces Medicare expenditures, the Balanced Budget Act of 1997 mandated that the Secretary of Health and Human Services conduct and evaluate care coordination programs in the Medicare fee-for-service setting.” Should, in this research, any of the components of these programs demonstrate effectiveness in reducing Medicare expenditures and improving quality of care for Medicare beneficiaries, under this legislation, they would be permanently implemented.

So, in 2002, the Centers for Medicare & Medicaid Services (CMS) competitively awarded grants to 15 health care programs to study care coordination. It also contracted with Mathematica Policy Research Inc. to conduct an independent evaluation of the findings. Their conclusions were reported in the current issue of the Journal of the American Medical Association.

This study has important implications, not only for how limited public healthcare resources are spent, but most importantly, the authors noted, this study would provide important answers to recent health policy interests in medical homes (managed care) as a way to improve care coordination, improve quality and reduce costs.

In this registered clinical trial [Id: NCT00627029], eligible Medicare patients at fifteen centers across the country were randomly assigned to participate in care coordination programs or a control group receiving usual care. These care coordination programs provided disease management for coronary artery disease, congestive heart failure, diabetes, COPD, cancer, stroke, depression and dementia.

This analysis, led by Deborah Peikes, Ph.D., and colleagues at Mathematica, used Medicare data from beneficiaries enrolled from April 2002 through June 2005, including claims through June 2006 to ensure follow-up data was available on all beneficiaries for at least one to four years. The study followed these patients for an average of 30 months. Only 14 of the programs completed the study, as one program proved nonviable and dropped out after 3 ½ years.

Findings

“None of the 15 programs generated net savings,” the authors found. “None of the programs reduced regular Medicare expenditures, even without the fees paid to the care coordination programs.” In fact, “for total Medicare expenditures including program fees, the treatment groups for 9 programs had 8% to 41% higher total expenditures than the control groups did, all statistically significant,” they said.

“These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined,” the authors concluded. Compared to the patients receiving usual care, slightly more of those participating in the care coordination program recalled “receiving education during the preceding 12 months on diet, exercise, and warning signs of disease exacerbation, and receiving educational materials.” But the results for the other process measures were not uniformly positive, they said, “with only a few scattered effects for self-reported influenza and pneumococcal vaccinations, mammography, and various routine tests.”

The quality of care indicators (reported in supplemental data) had asked the participants if they understood “how to follow a healthy diet [and] the proper way to exercise, and how often they “followed a healthful eating plan, exercised regularly, missed dose of medications [and] visited physicians with list of questions.” The trials also evaluated how the participants scored on surveys of health-related quality of life and satisfaction with health care; and compared hospitalizations and mortality data.

While all of the programs that followed lifestyle quality indicators reported their programs had increased the percentage of participants exercising regularly, and 8 out of ten reported more patients were taking their prescribed medications, it proved to have no effect on reducing hospitalizations.

This study found that even after years of disease management, the programs had no effect on overall hospitalizations. The diabetes management programs, however, did notably worse. They resulted in more hospitalizations for diabetes and microvascular complications compared to the control groups in 10 and 9 of the programs, respectively.

The only mortality data reported was from the diabetes managed care interventions. They reported higher death rates in the intervention group in 7 out of 14 programs and lower in the other 7 programs.

Conclusions

The authors concluded: “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.” Nevertheless, the two programs showing potential promise were given the option to continue for three more years, with continued interim evaluations.

This study’s findings were more favorable than the negative results of two other efforts by CMS to introduce care coordination or disease management into Medicare, the authors said. Still, “it is clear that even if savings could be achieved they would be modest, even for the most successful programs,” they said.

Rather than additional third-party managed care, patients do just as well, if not better, when cared for by their own doctors.