Friday, June 6, 2008

Latest 3rd Report Medicare Coordinated Care Demonstration: The Good, Bad, Really Bad & Quote Most Likely to be Taken Out of Context (Part 1 of 4)

The Disease Management Care Blog obtained a copy of the latest 3rd Report Third Report to Congress on the Evaluation of the Medicare Coordinated Care Demonstration (MCCD). This is the latest four year update of the program.

The Medicare Coordinated Care Demonstration (MCCD) was included in the Balanced Budget Act of 1997 to test Care Coordination programs in Medicare fee-for-service sector. Fifteen programs in were selected to participate. They included a spectrum of commercial disease management providers, academic medical centers and hospitals in 16 States. Their programs used a mix of in-person initial assessments, home tele-monitoring, behaviorally based education and physician participation with tailored payments. The programs began in January 2001. Enrollment of the more than 18,000 beneficiaries (with a mean PMPM in excess of $2000 at baseline), who were randomly assigned to intervention and control groups, began between April and September of 2002. Fees paid to the programs per beneficiary ranged from $50-$444 per month.

According to Mathematica Policy Research, the bottom line was “most of the care coordination programs tested in this 3rd report had limited or no improvements in quality of care, few achieved cost neutrality and none reduced total Medicare expenditures when care coordination fees were included. Five programs had modest effects on quality without significantly increasing Medicare expenditures.”

Yikes. The DMCB read this through once and will continue to chew on this. In the meantime, here are some points gleaned from the report:

The Good News:

Across all programs combined, the treatment group had slightly fewer hospitalizations per year than the control group by 4.5% (p=.02). However, there was wide variation among programs and two programs in particular seemed to skew these positive results.

There were meaningful reductions in heart failure hospitalizations among patients with heart failure and among patients with diabetes.

Treatment group members were more likely to be satisfied in support and monitoring and health education. Physicians also agreed the programs made things easier.

There seemed to be noticeable increases in urine protein tests and A1c among persons with diabetes, lipids tests among persons with CAD and diabetes and there was an increase in overall flu shots and mammography.

Programs with the most in-person contact were generally more successful

The Bad News:

There was no effect on patients’ self report adherence to diet, exercise or taking medications.

No particular program types or target populations were consistently associated with favorable cost and quality outcomes

Programs lacked extensive care coordination experience and many lacked experience working with fee for service Medicare beneficiaries.

The Really Bad News

According to this analysis, increases in quality of care do not necessarily result in reduction in hospitalizations or costs.

The Quote Most Likely to be Taken Out of Context:

“Moreover, the findings contradict the oft-heard claims of disease management companies that they not only are cost neutral but substantially reduce total costs; in this demonstration, 10 of the 15 programs increased total Medicare expenditures when the costs of the intervention are included, and none of the other 5 actually reduced expenditures.”

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