March 19, 2004
Developing the Right Approaches to Chronic Care in Medicare
by Jane Horvath and Robert Berenson, MD
Effective chronic care for people with complex and multiple chronic
conditions requires the involvement of physicians and coordination among
multiple treating physicians Approaches to chronic care management have
become common in private sector health plans, however, Medicare is just
beginning to explore both the implications of chronic illness and
approaches to chronic illness care The recent Medicare Modernization Act
provides for testing a private sector vendor approach to chronic illness
care However, the approach is likely to be of limited benefit to a
significant portion of beneficiaries who have complex chronic care needs
Medicare has an important opportunity to develop truly new and effective
approaches to chronic care that take into account the different nature of
the senior population relative to the working age population for whom the
current private sector approaches are designed
INTRODUCTION
Americans are living longer than ever, in part due to new medical
treatments and technologies, and
better prevention and healthier
lifestyles However, people are living longer with chronic diseases –
diseases such as heart disease, diabetes and even some cancers Often,
diseases that used to be fatal early on, can now be effectively managed for
years And as we live longer, more of us live with multiple and complex
chronic conditions that require a high degree of medical management and
monitoring over time and a new commitment to encouraging patient self-
management
Policymakers are just beginning to realize the implications for Medicare of
living longer with chronic illness, particularly living with multiple
chronic diseases[i] In general, about 20 of beneficiaries have five or
more chronic conditions and account for over two-thirds of Medicare
spending Beneficiaries with five or more conditions see about 14
different physicians in a year and have almost 40 office visits[ii] The
chances of an otherwise unnecessary hospitalization– for conditions that
can and should be managed effectively on an outpatient basis– increases
from about 1 for a beneficiary with just one condition to about 13 for a
beneficiary with five conditions and again to about 27 for a person with
eight
chronic conditions[iii] It seems then that beneficiaries with
multiple chronic conditions have unattended complications despite their
high health care utilization It also appears that the number of chronic
conditions has more influence on health care spending than age does in the
Medicare population[iv]
WHAT THE LAW DOES
Section 721 of the Medicare Modernization Act MMA provides for a new
Chronic Care Improvement CCI program within the traditional Medicare
program; the law also requires a new emphasis on chronic illness management
within the Medicare Advantage program The CCI program is essentially a
vendor-operated, disease management program targeting beneficiaries with
chronic obstructive pulmonary disease, congestive heart failure, and
diabetes mellitus, and other conditions that the Secretary may specify
CCI is to be tested for three years after which the Secretary will evaluate
the program for financial outcomes program savings, clinical quality
hospital readmission rates and adherence to clinical guidelines, and
beneficiary satisfaction
In general, a CCI vendor must guide beneficiaries in managing their health
Every beneficiary enrolled with a vendor is to have a care plan
that is to
include disease self-management education, physician education and
collaboration with physicians and other providers to enhance communication
of relevant clinical information Care plans can also include use of
monitoring devices to facilitate transmission of clinical indicators CCI
vendors are to have a tracking system to follow each beneficiary across
settings and track outcomes in each setting
CONCERNS
Physicians Not Actively Involved The CCI program and traditional disease
management vendor programs do not address a core reality — that
beneficiaries personal physicians mostly are responsible for their care
and not health plans or disease management vendors Policymakers need to
address how to engage the front lines of health care utilization and
quality - doctors and other health care professionals In order to be
successful, effective case management/disease management needs the active
involvement of the physician[v] This CCI initiative is quite removed from
the physician even though the legislation calls for an individuals care
plan to include physician education and collaboration[vi]
Consistent with the overall philosophy of the MMA, the laws approach
to
addressing the growing need for improved care for those with chronic health
conditions is a corporate one, focused on providing contracts to third
party vendors, rather than enabling professionals to better serve their
patients Medicare has an important opportunity to lead the restructuring
of how physicians organize and deliver health services, as called for by
the Institute of Medicine in their seminal Quality Chasm Report[vii]
Instead, the MMA would have Medicare merely follow private sector
approaches that may not be well suited to the Medicare population
Working-Age Population Model Disease management developed in the context
of managed care plans that served the employer sponsored market
Therefore, disease management has generally applied to a working age
population with a much lower prevalence of medical complexity and multiple
comorbidities For instance, only seven percent of elderly Medicare
beneficiaries with diabetes have just that disease while fully 37 of
beneficiaries with diabetes have four or more additional conditions In
contrast, among the non-elderly with diabetes, 22 have only diabetes and
about 19 have four or more additional conditions[viii] A further
example
is found in Medicaid Even though disease management vendor programs have
become popular in Medicaid,[ix] people who are concurrently eligible for
Medicare are almost always excluded, so vendors have not gained experience
with medically complex elderly populations through this contracting
approach either
Disease management can bring important benefits to relatively healthy
individuals, particularly in terms of secondary prevention It is also
proper that CCI programs are required to identify and address enrollee
comorbidities However, these programs have not generally been designed to
successfully address the needs of medically complex patients, whose needs
go well beyond learning disease self
management techniques and who have multiple professionals affecting the
care and treatments of their different conditions It will be challenging
for
disease management companies and related vendors to develop the necessary
linkages with physicians, especially because the law provides no new reason
for physicians to engage with them Creating effective relationships with
treating physicians is further complicated by the probability that these
management companies will be operating
across great distances from a
central location with no particular connection to the communities in which
they will operate
Medicare disease management will be beneficial to a certain segment of
beneficiaries, and it would certainly be part of a comprehensive strategy
But it is not a sufficient response to the needs of a growing segment of
the Medicare population — medically complex individuals whose needs drive
program spending
Interaction with New Drug Benefit In administering the MMA, the Centers
for Medicare and Medicaid Services CMS also must pay special attention to
the potential that Part D stand-alone drug plans, which are required to
have a medication therapy management program, would work at cross purposes
with Chronic Care Improvement disease management programs, with the former
focused on reducing unnecessary prescription drug expenditures and the
latter attempting to improve compliance with prescribed drug regimen
IMPROVEMENTS
Focus on Physicians While CCI is likely to be helpful to younger,
healthier Medicare beneficiaries, CCI will not assist the 20 of the
program beneficiaries with five or more conditions on whose behalf over two-
thirds of program expenditures
are made Instead of the corporate, vendor-
oriented approach as embodied in the bill, it is time to return to basics
and think about interventions and incentives that target the professionals
who directly care for these medically complex individuals The successful
example of the Prospective Payment System for paying hospitals, which
produced greater hospital efficiency and corresponding reductions in
Medicare program costs, suggests that basic payment policy can be a
catalyst for modifying provider behavior In this case, physicians should
be paid and supported for taking responsibility for assertively
coordinating the care for patients with complex chronic conditions Part of
that coordination activity might involve interacting with nurses and others
from disease management vendors
One such model has appeared in slightly different forms in Medicare
legislation in the past two sessions of Congress, but ultimately lost out
to the corporate approach[x] This model, the complex clinical care
payment model, would place responsibility and accountability for clinical
care coordination of medically complex individuals with physicians and
their staffs acting under their direction
Participating physicians would
agree to coordinate clinical care, would consult with other treating
providers as necessary and would receive a monthly administrative payment
for the extra time and attention involved The model could be expanded in a
number of ways For example, physicians could be required to have, on
staff or under contract, a case management function to make referrals to
community resources that could address the supportive service needs of
these patients
CMS has a demonstration design that incorporates one approach to changing
the nature of physician practice — the physician group practice
demonstration However, it is limited to large, group practices that have
at least 200 full-time physicians and this demonstration addresses spending
for all beneficiaries cared for by the group Physicians would receive
bonus payments to the extent that spending is below established targets
This demonstration is on the right track, but it does not target the
population with multiple chronic conditions, and the size of the physician
group will limit the extent to which the model can be replicated if it
proves successful
CMS has numerous other demonstrations to test care
management/disease
management models However, all of them have design issues that will likely
limit their success for medically complex individuals Several of the
projects target specific diseases, rather than specifically targeting
beneficiaries with multiple conditions And the demonstration models
typically ignore addressing the crucial role of the treating physician in
care management
An example of a model that incorporates the clinical care management focus
and which could be adapted for Medicare is a program in Georgia - the
SOURCE program - for medically complex Supplemental Security Income
eligibles In this program, local entities case management agencies,
hospitals, aging agencies provide enhanced care management and recruit
physicians to work in tandem with the case managers The physicians
generally receive monthly per client administrative payments, agree to
provide clinical care coordination and agree to work closely with the
clients case manager who brings supportive services to the mix in support
of better medical outcomes These are all small area efforts, where local
agencies have the capability to develop relationships with doctors in the
community and call
attention to medical issues that might otherwise go
unnoticed and where aggressive case management tracks beneficiary use of
services - including other physicians and services that the primary care
physician might not otherwise have known about
Medicare has considerable ability to lead the necessary restructuring of
the practice of medicine and re-orient care to chronic care management The
MMA tilts far too much in the direction of a corporate, vendor solution for
aspects of the program that would be served better by involving those who
actually deliver health care on the front lines - physicians in their own
medical practices
———————–
[i] Among a number of recent policy documents that examine the issue of
chronic conditions and Medicare, is Eichner, June and Blumenthal, David,
eds Medicare in the 21st Century: Building a Better Chronic Care System
National Academy of Social Insurance Washington DC January 2003
[ii] Partnership for Solutions, Medicare: Cost and Prevalence of Chronic
Conditions Johns Hopkins University, Baltimore MD July 2002
[iii] Wolff J et al Archives of Internal Medicine, November 11, 2002
[iv] Berenson R, Horvath J, Clinical Characteristics
of Medicare
Beneficiaries and Implications for Medicare Reforms Prepared for the
Center for Medicare Advocacy, March 2002 Accessed February 2004,
wwwpartnershipforsolutionsorg/DMS/files/MedBeneficiaries2-03pdf It is
also true that the presence of chronic conditions is associated with age,
however, costs and utilization are similar for beneficiaries with multiple
chronic conditions regardless of age
[v]Chen, A , Brown, R; et al Best Practices in Coordinated Care Prepared
for the Health Care Financing Administration Mathematica Policy Research,
Princeton NJ March 2000 Accessed February 2004 at wwwmathematica-
mprcom/pdfs/bestsumpdf
[vi] Physician collaboration is one of the generally accepted defining
criteria for disease management programs; however, the extent of that
collaboration is highly variable
[vii] Institute of Medicine Crossing the Quality Chasm: A New Health
System for the 21st Century National Academy of Sciences Washington,
DC March 2001
[viii] Partnership for Solutions, unpublished data from the 2000 Medical
Expenditure Panel Survey conducted by the Agency for Healthcare Research
and Quality Johns Hopkins University, Baltimore, MD Data for heart
diseases are
similar 19 of the non-elderly with heart disease have only
heart disease, while only 8 of the elderly with heart disease have only
heart disease, while 37 have 4 or more additional conditions, compared to
24 of the non-elderly
[ix] As of July 2003, 23 States had some form of disease management DM
program in the Medicaid fee-for-service system Source: DMNOWorg website
accessed November 2003
[x] Most recently, the complex clinical care payment concept was included
as a demonstration in the Senate version of the Medicare reform
legislation, S 1, in June 2003, Section 443 The provision set new
participation standards for physicians willing to participate including
conducting a range of care coordination activities that linked medical and
supportive services oriented to the beneficiary and family caregivers
Source:txhca.org
