RESUMO
As one of the initial fifteen participants in the Medicare Coordinated Care Demonstration, the Washington University School of Medicine in St. Louis was not able to demonstrate any reduction in hospitalizations or Medicare spending for the patients it served. In fact, the Washington University program increased total Medicare spending by 12 percent. But after a redesign, the results changed. The program stopped conducting care management of most of its patients via telephone from a remote site in California and, instead, served all patients through frequent phone and occasional in-person contact from local care managers in St. Louis. Care management efforts were focused especially on patients deemed at greatest risk of hospitalization, and stronger hospital transition planning and medication reconciliation were provided, among other changes. After that point, the program reduced hospitalizations by 12 percent and monthly Medicare spending by $217 per enrollee-more than offsetting the program's monthly $151 care management fee. The results underscore findings from the overall Medicare Coordinated Care Demonstration that suggest that programs with more in-person contacts were more likely than others to build trusting relationships with patients and providers, improve patient adherence to care plans, and address additional needs and barriers that entirely telephonic contacts had been unable to identify. The results also indicate that programs can be more effective by focusing on the highest-risk patients, for whom the largest savings resulted.