Wednesday, September 21, 2011

Care Coordination: The Way Forward For The Dual Eligibles

Hot on the heals of the Disease Management Care Blog's bus tour of the problematic "dual eligibles"  comes this AHIP sponsored report from Emory health economist Kenneth Thorpe on how the Feds could save the taxpayers some serious money.   Recall that there are close to 9 million duals costing in excess of $230 billion per year and that the President's recent cost reduction proposal is curiously devoid of any mention of this group.

So what is Dr. Thorpe's recommendation?  It can be summed up in two words:

"Care coordination."  The report can be found here.

 As the DMCB previously noted, the duals are being victimized by a perfect misalignment storm of Medicare and Medicaid.  Dr. Thorpe recommends that they be automatically enrolled (on an "opt-out" basis) in State-regulated managed care plans that would finance 24-7 centralized team-based care that, in turn, would be required to offer three key evidence-based services:

1. Transitional care or comprehensive planning and follow-up as patients move from the hospital to the community, which is led by dedicated full-time nurses.

2. Coaching and education using motivational interviewing and behavior change theory that is designed to prompt changes in life-style and greater self-care.

3. Medication management under the direction of a full-time pharmacists who make sure that the right medicines are being taken at the right time.

Based on a host of papers that have examined the impact of the interventions described above, Dr. Thorpe estimates, depending on the number of opt-outs, that the savings could exceed a whopping $125 billion over ten years.

The physician-DMCB endorses Dr. Thorpe's recommendations:

While critics may charge that it gives too much power to the insurers, it thinks that the States and the Feds can ensure that there are consumer protections.  Witness the preliminary good work of the Special Needs Plans.

The report avoids drinking the "physician-centric" Kool-Aid that assumes some combination of electronic records and financial incentives will enable primary care docs to take this on.  They can't.

While the Patient Centered Medical Home (PCMH) is certainly an option, report capitalizes on the more important elements of the PCMH and discards the rest. 

Finally, it's the health plan that has the accountability - and the downside financial risk - for making this work in a high cost and particularly needy population.

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