Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients.

As policy makers seek to slow the growth in Medicare spending, they have appropriately focused attention on beneficiaries with multiple chronic conditions. Many care coordination and disease management programs designed to improve beneficiaries' care and reduce their need for hospitalizations have been tested, but few have been successful. This study, however, found that four of eleven programs that were part of the Medicare Coordinated Care Demonstration reduced hospitalizations by 8-33 percent among enrollees who had a high risk of near-term hospitalization. The six approaches practiced by care coordinators in at least three of the four programs were as follows: supplementing telephone calls to patients with frequent in-person meetings; occasionally meeting in person with providers; acting as a communications hub for providers; delivering evidence-based education to patients; providing strong medication management; and providing timely and comprehensive transitional care after hospitalizations. When care management fees were included, the programs were essentially cost-neutral, but none of these programs generated net savings to Medicare. Our results suggest that incorporating these approaches into medical homes, accountable care organizations, and other policy initiatives could reduce hospitalizations and improve patients' lives. However, the approaches would save money only if care coordination fees were modest and organizations found cost-effective ways to deliver the interventions.

Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials.

CONTEXT: Medicare expenditures of patients with chronic illnesses might be reduced through improvements in care, patient adherence, and communication. OBJECTIVE: To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries. DESIGN, SETTING, AND PATIENTS: Eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 in 15 care coordination programs (each received a negotiated monthly fee per patient from Medicare) were randomly assigned to treatment or control (usual care) status. Hospitalizations, costs, and some quality-of-care outcomes were measured with claims data for 18 309 patients (n = 178 to 2657 per program) from patients' enrollment through June 2006. A patient survey 7 to 12 months after enrollment provided additional quality-of-care measures. INTERVENTIONS: Nurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely. MAIN OUTCOME MEASURES: Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators. RESULTS: Thirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, Mercy had 0.168 fewer hospitalizations per person per year (90% confidence interval [CI], -0.283 to -0.054; 17% less than the control group mean, P=.02) and Charlestown had 0.118 more hospitalizations per person per year (90% CI, 0.025-0.210; 19% more than the control group mean, P=.04). None of the 15 programs generated net savings. Treatment group members in 3 programs (Health Quality Partners [HQP], Georgetown, Mercy) had monthly Medicare expenditures less than the control group by 9% to 14% (-$84; 90% CI, -$171 to $4; P=.12; -$358; 90% CI, -$934 to $218; P=.31; and -$112; 90% CI, -$231 to $8; P=.12; respectively). Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined. CONCLUSIONS: Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00627029.

15-site randomized trial of coordinated care in Medicare FFS.

Medicare beneficiaries in fee-for-service (FFS) who had chronic illnesses and volunteered to participate in 15 care coordination programs were randomized to treatment or control status. Nurses provided patient education (mostly by telephone) to improve adherence and ability to communicate with physicians. Patients were contacted an average of two times per month. The findings after 2 years are not encouraging. Few programs improved patient behaviors, health, or quality of care. The treatment group had significantly fewer hospitalizations in only one program; no program reduced gross or net expenditures. However, effects may be observed when 4 years of followup are available and sample sizes increase.

Impacts of a disease management program for dually eligible beneficiaries.

The LifeMasters Supported SelfCare demonstration program provides disease management (DM) services to Florida Medicare beneficiaries who are also enrolled in Medicaid and have congestive heart failure (CHF), diabetes, or coronary artery disease (CAD). The population-based program provides primarily telephonic patient education and monitoring services. Findings from the randomized, intent-to-treat design over the first 18 months of operations show virtually no overall impacts on hospital or emergency room (ER) use, Medicare expenditures, quality of care, or prescription drug use for the 33,000 enrollees. However, for beneficiaries with CHF who resided in high-cost South Florida counties, the program reduced Medicare expenditures by 9.6 percent.

Consumer enrollment and experiences in the Cash and Counseling program.

STUDY CONTEXT: Consumer direction of Medicaid supportive services raises concerns about who should be permitted to self-direct, whether consumers should be allowed to pay family members, whether a self-directed option increases demand for services, and how to ensure quality. The Cash and Counseling programs contained features designed to address these concerns. DEMONSTRATION ENROLLMENT: Many consumers used representatives to manage the allowance on their behalf and others chose to disenroll, suggesting that beneficiaries were capable of deciding for themselves whether the programs were suitable for them. Participation among eligible beneficiaries during the demonstration was modest, suggesting that consumer direction did not itself substantially increase the demand for services. CONSUMER EXPERIENCES: Most consumers were able to assume the role of employer without difficulty, many hiring relatives or acquaintances as workers. In each state, more than 85 percent reported they would recommend the program to others seeking more control over their care, and more than half said the program had "improved their lives a great deal."

Improving the quality of Medicaid personal assistance through consumer direction.

As states seek to improve home and community-based services for people with disabilities, many are incorporating consumer-directed supportive services into their Medicaid programs. The national Cash and Counseling Demonstration uses a randomized design to compare an innovative model of consumer direction with the traditional agency-directed approach. This paper presents findings from the first demonstration program to be implemented, in Arkansas. Our survey of 1,739 elderly and nonelderly adults showed that relative to agency-directed services, Cash and Counseling greatly improved satisfaction and reduced most unmet needs. Moreover, contrary to some concerns, it did not adversely affect participants' health and safety.

Racial disparities in prescription drug use among dually eligible beneficiaries.

Well-documented racial disparities in use of medical services raise concerns about such disparities in other aspects of health care. We compare the difference in Medicaid pharmacy use between black and white dually eligible Medicare beneficiaries. Controlling for the presence of chronic illnesses, we find that black beneficiaries have significantly fewer prescriptions filled and lower pharmacy costs in 8 of the 10 States examined, despite having higher physician costs. If this disparity stems from a lack of provider or beneficiary knowledge, programs to educate providers or beneficiaries may hold the greatest promise for reducing it, whether pharmacy coverage is obtained from Medicaid or from a new Medicare benefit.

The effects of cash and counseling on personal care services and Medicaid costs in Arkansas.

The Cash and Counseling Demonstration gives Medicaid beneficiaries who are eligible for personal care services a consumer-directed allowance in lieu of traditional agency services. Using survey and Medicaid claims data on 2,008 adult applicants randomly assigned to treatment or control groups, we find the program increased the receipt of paid care but reduced unpaid care. The treatment group had higher Medicaid personal care expenditures than controls did, because many controls received no paid help, and recipients obtained only two-thirds of entitled services. By the second year after enrollment, these higher personal care expenditures were offset by lower spending for nursing homes and other Medicaid services.