Sunday, January 29, 2012

Congressional Budget Office Concludes Medicare Remains Incapable of Implementing Disease Management and Care Coordination

By now, many readers may be familiar with the recently released Congressional Budget Office (CBO) report Lessons from Medicare's Demonstration Projects on Disease Management and Care Coordination

The Disease Management Care Blog finally caught up with it. 

Here's its take:

It's a well-written and traditionally crafted summary of CMS' six demonstrations that had the participation of 34 programs:

Care Management for High Cost Beneficiaries
Medicare Coordinated Care
Disease Management for Dual Eligibles
Informatics for Diabetes Education and Telemedicine
Disease Management for Severely Chronically Ill Beneficiaries
Medicare Health Support

Why Demos?

Demos are used by CMS to test innovative care strategies before they are formally adopted as a covered benefit in the fee-for-service program. These demos were funded because CMS knows that half of all Medicare beneficiaries have five or more chronic conditions and that they account for 75% of its costs. In addition, up to 50% of beneficiaries are not receiving recommended care, such as vaccinations and cancer screening.

How Did the Demo's Work?

The programs enrolled persons with a variety of chronic conditions such as diabetes and heart failure. Kick off dates ranged from 2000 to 2005. "Hierarchical condition categories" or high baseline expenditures were used to identify and target the persons at high risk. All used care coordination nurses who were typically - but not always - remote and disconnected from the physicians. There was little information on admission criteria to the programs, on the training or credentials of the care managers, the approaches used in to manage transitions across care settings or improving medication compliance.

What Was the Bottom Line?

On average, the programs were unable to achieve savings in excess of Medicare's fees.

The programs reduced hospitalizations by an average of 7%. In order for Medicare to have saved money based on the disease management fees, the hospitalizations would have had to be reduced by 11%. Programs that involved greater in-person interactions between nurses and patients appeared to have greater success in reducing admissions rates.

The evaluation was also statistically stymied by relatively low numbers of patients in some of the programs. It is possible that there were savings, but if they exist, they were too small to be detected by widely accepted statistical methods.

So What DMCB Conclusions Can Be Drawn and Why?

There are two:

1.The "versions" of disease management used by Medicare from 2000-2005 relied on approaches used in commercial settings from 1995-2000. These deployed remotely stationed nurses calling patients with worrisome cost patterns. From 2000-2005, commercial insurers and employers knew that wasn't working and transitioned to more sophisticated engagement protocols as well as in-person care programs tailored for patients with high as well as modifiable risk.

In other words, the impact of later versions - like this, this and this - of disease management in fee-for-service Medicare remains largely unknown. That's why the CBO report ends with the conclusion that....

"...the demonstration results indicate that additional experimentation, evaluation, and refinement over a period of years will probably be needed to identify policies involving disease management and care coordination that can significantly reduce Medicare expenditures."

Of course, by the time CMS gets done with more years of "experiments," "evaluation" and "refinement," those results will likewise be obsolete.

2. This begs the question: if Medicare can't achieve savings, why do practically all insurers and most self-insured employers still include disease management programs in their benefit designs?

The DMCB suggests that in addition to a growing body of peer-reviewed literature showing that more modern (and still untested by Medicare) disease management is "efficacious," non-governmental insurers have some additional advantages that increase real world effectiveness:

1.Using disease management as only one component in an overlapping suite of other mutually supportive programs, including consumer-based incentives to rely on primary care, value-based insurance designs, intelligently restricted networks and concurrent wellness and prevention programs.

2. Access to internal assessments of program success that will never be submitted for publication in the peer reviewed literature.

3. Flexible program adaptation to the myriad local cultural and community factors that determine success. After all, what works in a motorcycle factory in the Midwest may not work in a cubicle farm in Silicon Valley.

The DMCB Bottom Line:

While the CBO report is technically correct, it promotes the tired canard is that modern disease management consists of naive nurses making blind calls and exhorting baffled consumers to take better care of themselves. In addition, the idea that single standard can be implemented everywhere in a stand-alone fashion is a pipe dream. No wonder Medicare's disease management demos have failed.

The Feds need to figure out how to implement disease management, not what doesn't work.

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