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Cutting Medicare Costs for Complex Patients

A new study of three existing programs seeks the elixir of quality health care at affordable prices for elderly patients with lots of chronic diseases.

For all the political chatter about fraud, waste and abuse, one big reason that Medicare costs so much is that old people get sick.

And the relatively small group of patients, those with four or five chronic diseases, is particularly expensive; some researchers estimate these patients account for 75 to 80 percent of Medicare spending. In the current health care system, rife with duplication, fragmentation and off-kilter payment incentives, much of the care for the chronically ill elderly is not particularly coordinated, evidence-based or efficient.

In recent years, health care innovators around the country have tried approaches to providing better care coordination, aiming to manage chronic diseases, keep people out of the hospital and create sensible connections between medical and social services, such as transportation to a doctor’s appointment. The health reform legislation contains tools and incentives for developing more programs like this that aim to provide higher quality care at a lower cost — an aspect of reform that is often forgotten amid the partisan crossfire about repealing or defunding the legislation. But no one really knows for sure yet which programs hold the most promise or which will prove widely adaptable to a variety of community settings.

A study published recently in the Journal of the American Medical Association examines some of the better known models that, with a little tweaking in a post-health reform world, could lead to that elixir of high quality at lower cost. The survey found solid evidence that programs can improve the quality of care as well as satisfaction for patients, families and even doctors. But saving money while improving care is more of a challenge — possibly, some experts believe, because it may take a few years for these programs to hit their stride.

“These are the kind of models we need to look at,” said Melanie Bella, the head of the a new federal office tasked with trying to make Medicare and Medicaid mesh better, nationally and at the community level. (Medicare is a federal program for the elderly and disabled; Medicaid is a joint federal-state program for the poor, including many elderly and disabled.)

“We have learned a lot. We have some experience now in how to construct different models,” said Dr. Chad Boult, the co-author of the JAMA report and one of the creators of Guided Care at Johns Hopkins, one of the promising chronic care approaches reviewed. But challenges remain, ranging from outdated ways of training doctors to disjointed ways of paying for coordinated care, added Boult, who recently began work at the new federal Center for Medicare and Medicaid Innovation, created under the health reform law to try to improve and disseminate promising care approaches.

The JAMA study homed in on three programs — Hopkins’ Guided Care, Indiana’s GRACE and the national PACE. (Boult also reviewed the data on a Veterans Administration home-care program that improved quality but added cost. That was a 2000 study based on care provided in the 1990s, and he didn’t discuss it at length in the JAMA article).

PACE, or the Program of All-inclusive Care for the Elderly, is the oldest and best known, dating back to the 1990s. It serves mostly low-income patients who are sick enough to qualify for a nursing home but are trying to remain in the community. Many have dementia, and many PACE enrollees need help with such basic daily activities as dressing or bathing.

The program receives lump sums of money (known as capitation) from both the federal Medicare program for the elderly and Medicaid, the joint state-federal health program for the poor. PACE uses that payment to cover both social and medical services, based at an adult day health center. But PACE remains expensive, and only about 30 states have bought in. The programs remain small, a drop in the demographic bucket.

GRACE, for Geriatric Resources for Assessment and Care of Elders, was developed by Dr. Steven Counsell and colleagues at Wishard Health Services in Indianapolis. An advance-practice nurse and a social worker collaborate with primary care doctors in community clinics to care for low-income elderly patients, most of whom are quite frail. An interdisciplinary geriatrics team can review care, injecting an extra note of expertise to the primary team. Through in-home assessments and telephone monitoring, GRACE targets a dozen problems that are common among older Americans, ranging from dementia and hearing loss, to managing multiple medications, to supporting family caregivers, emotionally and practically.

Does it pay off?

Boult found a mixed but improving picture. GRACE patients had high-quality care and were in the emergency room less often in year one. In year two, both ER and hospital admissions dropped for the sickest patients, but there was no difference overall in patients’ function or satisfaction. Nor did total costs drop. “We broke even,” said Counsell.

Year three, though, got interesting. The two-year grant-funded trial ended — but the costs started dropping. For the sickest, highest-risk patients, costs fell by 23 percent.

Counsell explained in an interview that successful primary care, particularly with a high-needs, hard-to-serve population, depends on relationships — relationships between doctors and nurses and social workers who may not be used to working together in this type of interdisciplinary team, and relationships between that care team and the patients and families.

“You grow into your program,” Counsell said. “Relationships and trust build, particularly as the nurse practitioners and the social workers make home visits. They help work through social issues, set medical goals, help the patients self-manage and get the medications straightened out.”

Once the trust is established, patients become more engaged in their own care and may be more willing to change their approach. After a year or two, Counsell said, “Maybe the patient will say, ‘OK, I will try that antidepressant,’ or maybe they will say, ‘OK, I trust you, I will get off this medication. Maybe it is what’s making me fall.’”

“All that takes time to play out,” added Counsell, who is helping other health systems elsewhere in Indiana and as far away as Southern California, adapt GRACE.

At Johns Hopkins, Guided Care has some similarities. Two to five primary care physicians partner with a specially trained nurse to provide comprehensive care to high-risk patients who are 55 and older. The nurse also helps the patient and family connect to community services, weaving health and social-support pieces together. The nurse also coordinates with the assorted medical specialists that may also see the patient. Families taking part in Guided Care have lower levels of stress and depression.

The JAMA study was limited to programs with solid data from well-designed trials. That doesn’t mean that other programs for the chronically ill across the country aren’t working, but the research base and evaluation weren’t rigorous enough for inclusion in this particular analysis. Nor does it rule out the possibility that the programs surveyed won’t do better on the bottom line as they mature as those involved get accustomed to interdisciplinary work teams, as they fine-tune their approaches to their patients’ complex needs.

With health reform broadening the horizon for experimentation and creating more flexible ways of paying for coordinated care, Boult and coauthor G. Darryl Wieland of Palmetto Health Richland Hospital in Columbia, S.C., weren’t just interested in making a short list of promising programs. They wanted to identify what makes them promising. They found several hallmarks of successful coordinated care.

First, the care team must be able to do a comprehensive assessment of all the diseases, conditions, disabilities and limitations, as well as assessing the patient’s family and support system.

That sounds obvious, but right now, a patient may have a cardiologist, pulmonologists, endocrinologist, ophthalmologist, neurologist or a half dozen “-ists” without anyone having a particularly clear image of the whole patient — or what the patient wants.

The patient needs a “comprehensive evidence-based plan” that takes into account those multiple challenges and conditions. And the patient, or the family, needs to be involved in “self-care,” the home-based care and monitoring. And communication is key, but too often the current system makes communication difficult — and unprofitable. Good communication has to encompass not just a doctor and a patient (or his daughter-in-law), but all the doctors in and out of the hospital, the emergency department, rehab centers, mental health services, home health aides, social workers and anyone else in the picture.

Today, that’s not how the medical system works. And it’s not how doctors are trained.

“We don’t routinely train our doctors, nurses and social workers to take care of people with multiple chronic conditions,” Boult said. “We train them to take care of one condition at a time.” Nor do we pay doctors to treat a bunch of complicated medical and social conditions at once. It’s easy for a physician to bill for a test or procedure, but he or she isn’t paid for making a phone call just to see how a patient is doing.

“Simply trying harder and working smarter cannot overcome this,” Boult told a recent Washington briefing on his research.

The culture of medicine is also a factor, noted Joshua Wiener, a leading researcher on aging, disability and long-term care at RTI International, who was not involved in the JAMA report. “The culture of medicine rewards dramatic interventions that save lives and bring people back to health.” But that’s TV drama. It’s not the chronically ill elderly.

The challenge for health care today isn’t miracle cures. It’s how to help people live with hypertension and heart failure and arthritis and dementia and lung disease and incontinence, and maybe a bit of failing hearing and vision.

“We’re talking about a population that at best is going to be stabilized — with multiple disabilities and multiple chronic illnesses,” Weiner said. “They are going to be fragile, disabled sick people. It takes a style of medicine that most physicians aren’t interested in providing.” Witness the relatively low proportion of young doctors that choose primary care — let alone geriatrics. And witness the amount of money they earn, compared to, say, an orthopedist or a radiologist.

But Boult and Wieland see reason for optimism. New models can flourish under reform, including integrated systems or “medical homes” that will get paid for disease management and care coordination. Health IT, with its potential for tracking and monitoring complex patients, is spreading. And doctors and hospitals will have opportunities to retool, or maybe reinvent, how they care for the elderly.

”A growing cadre of U.S. primary care providers will have opportunities to care for the chronically ill patients more effectively and efficiently,” they concluded. The elderly can have better health and more independence. Their families can have less stress. And if all goes well, a few years from now, we may even have lower costs.

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