Wednesday, October 26, 2011

Do Medicare Beneficiaries Warrant Higher Nurse-Patient Care Coordination Ratios?

In yesterday’s posting on care management nurse-staffing ratios and their associated costs, Peter McMenamin pointed out that a per member per month cost (PMPM) that ranged from $8 to $17 was a reasonable estimation.  What's more, it compared favorably to the monthly management fee in the Comprehensive Primary Care Initiative. 

This is also important for Accountable Care Organizations that are grappling with the amounts that they’ll need to invest in care coordination to achieve the shared savings.  Assuming an ACO becomes accountable for 5,000 beneficiaries, that calculates out to between $480,000 and $1,020,000 per year.

But, asked the Disease Management Care Blog, should there be any differences in care management ratios and costs for Medicare, Medicaid and commercial insurance?  If it’s a commercial ACO, should it estimate $500K, while a Medicare ACO should plan lower ratios and invest $1M?

Peter McMenamin’s thoughts:

A parity between Medicare, commercial, and Medicaid is possible but not exactly plausible.  Thanks to many co-morbidities, Medicare patients have more different docs, more visits, and more drugs.  Unless they are particularly compliant with respect to medications, you’d expect Medicare patients to be more demanding.  Unless they return to a physician so frequently that care coordination is incidental or are hospitalized so much that their care is taken care of, they need considerable care management. If Medicare patients take more time for follow-up, etc. that might explain the difference between $20 PMPM and the somewhat lower PMPM estimates from my calculations.

Good point, of course.  Yet the DMCB is not so sure that there is a correlation between savings and the intensity of care management beyond a certain threshold for any patient of any age.  In addition, while persons with Medicare have greater illness burden, that doesn’t mean the day-to-day management, care plans and shared decision making for conditions like diabetes or heart failure making varies depending on a patient’s age.

Dr. McMenamin and the DMCB will keep their eye out for answers.  More to follow.

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