A Call for Clarity in Care Coordination

1
A Call for Clarity in Care Coordination

• Robert A. Berenson, M.D.
• Senior Fellow, The Urban Institute
• ASA-NYAM National Forum on Care Coordination
• Las Vegas, 17 March 2009

2
Hospitalizations by Number of Chronic Conditions
Source G. Anderson, Hospitals and Chronic
Care, PowerPoint Presentation to the American
Hospital Association. Partnership for Solutions.
16 June 2004. MEPS 2000.
3
Hospitalizations for Ambulatory Care Sensitive
Conditions
Sources Partnership for Solutions. Multiple
Chronic Conditions Complications in Care and
Treatment, May 2002 Medicare Standard Analytic
File, 1999.
4
Activity Limitations by Number of Chronic
Conditions
Source G. Anderson, Hospitals and Chronic
Care, PowerPoint Presentation to the American
Hospital Association. Partnership for Solutions.
16 June 2004.
5
Annual Prescriptions by Number of Chronic
Conditions
49.2
33.3
24.1
17.9
10.4
3.7
Includes Refills Sources Partnership for
Solutions, Multiple Chronic Conditions
Complications in Care and Treatment, May 2002
MEPS, 1996.
6
Utilization of Physician Services by Number of
Chronic Conditions
Sources R. Berenson and J. Horvath, The
Clinical Characteristics of Medicare
Beneficiaries and Implications for Medicare
Reform, prepared for the Partnership for
Solutions, March, 2002 Medicare SAF 1999.
7
Breakdown of Total Health Care Spending
78 Health Care Spending
for People with Chronic Conditions
22 Health
Care Spending for People without Chronic
Conditions
Sources Partnership For Solutions, Chronic
Conditions Making the Case for Ongoing Care,
December 2002 MEPS, 1998.
8
Share of Health Care Expenditures per Coverage
Type
Sources Center on an Aging Society, Disease
Management Programs Improving Health While
Reducing Costs? January 2004.
9
Medicare Spending on Beneficiaries with Chronic
Conditions
Source G. Anderson, Hospitals and Chronic
Care, PowerPoint Presentation to the American
Hospital Association. Partnership for Solutions.
16 June 2004.
10
Medicaid Spending on Beneficiaries with Chronic
Conditions
SourcesAnderson, Gerard, Hospitals and Chronic
Care, 16 June 2004. Partnership for Solutions
MEPS 2000.
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Physicians Cant Do All of What is Needed By
Themselves
12
The Tyranny of the Urgent

• Amidst the press of acutely ill patients, it is
  difficult for even the most motivated and
  elegantly trained providers to assure that
  patients receive the systematic assessments,
  preventive interventions, education, psychosocial
  support, and follow-up that they need. (Wagner
  et al. Milbank Quarterly 199674511.)

13
The Pressure of the 15 Minute Visit

• Across the globe doctors are miserable because
  they feel like hamsters on a treadmill. They must
  run faster just to stand stillThe result of the
  wheel going faster is not only a reduction in the
  quality of care but also a reduction in
  professional satisfaction and an increase in
  burnout among physicians. (Morrison and Smith,
  BMJ 2000 3211541)

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How Patients are Affected

• Asking patients to repeat back what the physician
  told them, half get it wrong. (Schillinger et al.
  Arch Intern Med 200316383)
• Patients making an initial statement of their
  problem were interrupted by the PCP after an
  average of 23 seconds. In 23 of visits the
  physician did not ask the patient for her/his
  concerns at all. (Marvel et al. JAMA 1999
  281283)

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Incidents in the Past 12 Months
Among persons with serious chronic conditions,
how often has the following happened in the past
12 months? (Harris, Survey 2000)

• Been told about a possibly harmful drug
  interaction
• Sent for duplicate tests or procedures
• Received different diagnoses from different
  clinicians
• Received contradictory medical information

• Sometimes or often
• 54
• 54
• 52
• 45

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The Issue of Readmissions

• In Medicare, about 11 of patients are readmitted
  within 15 days and almost 20 within 30 days
• 50 of patients hospitalized with CHF are
  readmitted within 90 days
• The large majority of readmissions are
  preventable declining with time from index
  admission
• Half of beneficiaries discharged to community and
  readmitted within 30 days after medical DRG had
  no bill for physician services in the interval

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What Is To Be Done?

• -- V.I. Lenin

18
Lots Has Been Tried Unfortunately, Mostly
Unsuccessfully

• Peikes et al (JAMA, Feb 11, 2009) 13 of 15
  Medicare care coordination demo sites showed no
  significant differences in hospitalizations. None
  of the 15 generated net savings in costs,
• Berenson et al (AARP PPI, Dec 2008) a review of
  nearly 30 years of FFS and capitation demos of
  various approaches to chronic care management and
  coordination showed some improvement in quality
  but virtually none with program savings.

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Discussions of Care Coordination Suffer From a
Lack of Clarity On

• Target populations
• Definitions and specifications of the various
  interventions
• Locus of activity/organizational sponsorship

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Different Patients Need Different Kinds of Care
Coordination

• It is not clear that distinguishing patients by
  number of chronic conditions helps (despite its
  usefulness for analytic purposes)
• A cognitively intact patient with one or more
  well defined chronic condition may benefit from
  physician/pharmacist/other clinician coordination
  and system navigation help

21
There Are Chronic Conditions and Then There are
Chronic Conditions

• Part of the increase in percentage of population
  with chronic conditions derives from lowered
  thresholds for diagnosis and treatment
  secondary prevention. e.g., hyperlipidemia.
  (These are not even technically chronic
  condition, as no disability)
• Major chronic conditions lead inexorably to death
  but with different trajectories, i.e., CHF,
  COPD, cancer (Joanne Lynn)

22
Patients With Cognitive Impairments and Problems
with ADLs and IADLs Are Different

• As suggested to me by a geriatrician, patients
  with geriatric syndromes no longer are defined by
  their chronic conditions but rather by their
  limitations
• The nature of interventions and care management
  and coordination is different because clinical
  challenges and goals of care are different

23
Examples of Patients in Geriatric House Call
Program

• 99 year old with hemiplegia from a stoke, lives
  alone, and needs a personal service aide. Issue
  can she continue to live in her own home?
• Elderly male with renal failure from obstruction
  (from untreated prostate enlargement, seizure
  disorder, hypertension, dementia from brain
  infarcts, smoker Issue -- does not qualify for
  Medicaid or HH services under Medicare but needs
  homemaker services
• Care coordination here is about social
  services, mobilizing community services, as well
  as the logistics of accessing the health care
  system

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Lack of an Accepted Typology for the Possible
Interventions

• SWLI/NYAM categories
• Care coordination
• Case management
• Disease management
• Transitions in care
• Patient navigator
• Medical home

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Hofmarcher et al, Improved Health System
Performance Through Better Care Coordination
(OECD, Dec 2008)

• Care management
• Case management
• Continuing care
• Disease management
• Episodes of care
• Patient pathways

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Care Management is Defined in MIPPA and CMS
Regs for SNPs

• Target a chronic condition or institutional
  special needs population (as defined for SNPs)
• Annual comprehensive health risk assessment
• Interdisciplinary team to manage care
• Individualized care plan with objectives,
  measurable outcomes, and specific benefits and
  services
• Provider network with appropriate specialists
• Nationally recognized protocols and guidelines

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Care Management Requirements for SNPs (cont.)

• Integrated systems of communication
• Coordinate across settings and providers, i.e.,
  care transitions
• Train all staff on model of care
• Deliver services to vulnerable within target
  population frail, multiple chronic conditions,
  and those near the end of life
• Add-on services and benefits that meet
  specialized needs
• Lines of accountability to assure full
  implementation
• Evaluate effectiveness of the model of care

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Suggested Organizational Loci for Carrying Out
Care Coordination or Care Management -- or
Whatever It Is (In order of complexity)

• A physician with more time concierge practices,
  ideal medical practice
• Independent care coordinators?
• Geriatric house calls see Independence at Home
  Act action is in the patients home
• Patient-centered medical home with a
  multidisciplinary team in the practice

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Organizational Loci (cont.)

• PCMH but with a virtual team the
  complementary care is in the community see CCN
  of North Carolina, Vermont, Middlesex (Conn)
  physician group practice demo in Medicare
• Multispecialty group/Accountable Care
  Organization theoretically, can also address
  care across specialist silos
• Hospitals esp re transitions growth of
  employed physicians makes it plausible if changed
  payments

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Organizational Loci (cont.)

• Home health agencies -- how well does it work
  already for Medicare homebound is this a fair
  test of the virtual team concept?
• Health plans generally seem to be moving from
  disease management to support of something in the
  community closer to the physicians
• Special needs plans specifically despite
  compelling logic, little actually known

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Conclusions

• We have a lot to do to get this right whatever
  this is. Do not overpromise
• Given the documented problems in care for the
  various populations that might be improved and
  the stakes, it is worth the effort
• There are lots of proponents/would-be
  stakeholders, each with a claim to some part of
  the solution, but so far they seem to be mostly
  talking past each other or actually competing
• It is time to bring in the patients and
  caregivers to provide some reality testing