JAMA: Most Medicare coordinated care programs do not improve outcome, save money

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Only two of 15 Medicare programs designed to improve care and costs for patients with chronic illnesses, such as coronary heart disease and heart failure, resulted in reduced hospital admissions, and none of the programs generated net savings, according to a study in the Feb. 11 issue of the Journal of the American Medical Association.

High expenditures are generated by Medicare beneficiaries with chronic illnesses, driven primarily by hospital admissions and readmissions, according to the authors. Some studies have suggested that interventions to address the barriers faced by chronically ill patients could reduce avoidable hospitalizations and decrease expenditures.

To study whether coordination improves the quality of care and reduces Medicare expenditures, in 2002 the Centers for Medicare & Medicaid Services (CMS) competitively awarded 15 demonstration programs to various healthcare programs.

Deborah Peikes, PhD, and colleagues from the Mathematica Policy Research at Princeton, N.J., analyzed the results from randomized controlled trials of 15 programs on how they affected Medicare expenditures and quality of care. The programs included 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 and were randomly assigned to treatment or control.

Researchers measured hospitalizations, Medicare expenditures and some quality-of-care outcomes with claims data for 18,309 patients (178 to 2,657 per program) from patients' enrollment through June 2006. A patient survey seven to 12 months after enrollment provided additional quality-of-care measures. Nurses provided patient education and monitoring to improve the ability to communicate with physicians and adherence to medication, diet, exercise and self-care regimens. Patients were contacted twice per month on average; frequency varied.

The investigators found that 13 of the 15 programs showed no significant differences in hospitalizations. Mercy Medical Center in Des Moines, Iowa, significantly reduced hospitalizations by 17 percent, and Charlestown retirement community in Maryland had an increase of 19 percent more hospitalizations.

No program reduced regular Medicare expenditures. Treatment group members in three programs [Health Quality Partners (HQP) in Doylestown, Pa., Georgetown in Washington, D.C., and Mercy] had monthly Medicare expenditures less than the control group by 9 to 14 percent. Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. For total Medicare expenditures including program fees, the treatment groups for nine programs had 8 to 41 percent higher total expenditures than the control groups did, all statistically significant.

For the survey-based outcomes-of-care measures, despite reporting much higher rates of being taught self-management skills, treatment group members were no more likely than control group members to say they understood proper diet and exercise, or to state that they were adhering to prescribed or recommended diet, exercise and medications.

"Despite these underwhelming results for care coordination interventions in general, the favorable findings for Mercy and HQP suggest that the potential exists for care coordination interventions to be cost-neutral and to improve patients' well-being," the researchers wrote.

In an accompanying editorial, John Z. Ayanian, MD, of Brigham and Women's Hospital in Boston, wrote that the study offers two important insights to guide Medicare policy on coordination of chronic disease care going forward.

"First, care coordinators must interact in person with patients and not simply educate or assist them by telephone. Only four of the 15 programs emphasized in-person contact between coordinators and participants, including both of the programs that CMS allowed to continue," he wrote.

"A second crucial lesson is that care coordinators must collaborate closely with patients' physicians to have a reasonable prospect of influencing care. Only four of the 15 programs had coordinators who were based in physicians' offices or who attended patients' medical appointments, including both of the programs that were authorized by CMS to continue," Ayanian concluded.