Wednesday, January 6, 2010

Why Would the U.S. Senate Want to Continue to Support the Medicare Coordinated Care Demonstration (MCCD) As Part of Health Reform?

The Disease Management Care Blog undertook another exploration of the U.S. Senate's 'Manager’s Amendment' to its proposed health reform legislation and discovered some interesting language on page 155.

It directs the Secretary of Health and Human Services to….

Utiliz(ing) a diverse network of providers of services and suppliers to improve care coordination for applicable individuals … with 2 or more chronic conditions and a history of prior-year hospitalization through interventions developed under the Medicare Coordinated Care Demonstration Project under section 4016 of the Balanced Budget Act (bolding from the DMCB).

Continuing the Medicare Coordinated Care Demonstration (MCCD)? Where did that come from?

Regular readers of the DMCB may recall that the MCCD was something of a disappointment that was spun in a way that would make even Madam Speaker Pelosi proud. Briefly, it was a Medicare demonstration involving 15 healthcare organizations (5 disease management organizations, 3 community hospitals, 3 academic medical centers, 1 integrated delivery system, 1 hospice, 1 long-term facility and 1 retirement community) that randomized their established Medicare fee-for-service beneficiaries with chronic illness and prior hospitalization to usual care versus being assigned care coordinators tasked with increasing patient self-care. Final fees ranged from $60 to $270 per member per month (PMPM).

Of the 14 that completed the demo, only one achieved a statistically significant reduction in hospitalizations. Two programs had a significant change in costs, but in the wrong direction: both went up. Two other programs had non-statistically significant reductions in cost; if outlier costs were deleted from the analysis, one turned statistically significant. The abstract appearing in JAMA included statements like ‘…thirteen of the 15 programs showed no significant differences in hospitalizations…,’ as well as ‘…none of the 15 programs generated net savings…’ and, last but not least, ‘these programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined.’

Does this sound like something that should be continued as part of health reform?

DMCB doesn't blame the 14 centers for using whatever political legerdemain it took to continue the funding of this non-compete gravy train. Based on these data, however, it’s clear that while this particular nurse-coordinator model of care may have some promise, it alone is not enough to achieve the breakthroughs necessary to solve the twin health care challenges of cost and quality.

Better to use the MCCD's lessons by building an initiative (and please, not another ‘demo’) that takes what is known to work and not work from this as well as other demos and programs inside and outside of government to fashion a multi-pronged approach to population-based care. This should include the best of remote and face-to-face disease management, the medical home and other care coordination and physician led strategies. What’s more, the DMCB thinks it be smart to open this to other entities with fresh approaches. There should be a special emphasis on collaborative partnerships involving multiple players including the primary care doctors. Not only does this hold greater promise of ‘generating net savings’ and ‘having favorable effects on quality of care,’ but it’s the most likely to work in multiple settings across the country.

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