Health Affairs sponsored a briefing on the major articles in their June 2012 Issue entitled “Focus on the Care Span for the Elderly and Disabled”. “Care Span” is a new term for the full spectrum of services used by the elderly and disabled including acute care, chronic care and long term care services and supports up to and including death. The focus of the articles is on delivery system reform – i.e. how to reduce the fragmentation in these care systems, putting the patient at the center and improving transitions with the goals of improving the quality and outcomes of care while reducing costs. http://content.healthaffairs.org/content/31/6.toc
Several of the articles highlight efforts to improve care for a subset of the population that are the
most frequent users of the Care Span. Dual eligibles have coverage under both the Medicare and Medicaid programs but still face daunting challenges in accessing care that is efficient and meets their needs. The researchers emphasized that the interventions need to focus on integration of the financing and the two benefit packages while tailoring the interventions to very distinct subsets, e.g. the disabled and the frail elderly. Barbara Edwards from CMS discussed the many new programs and demonstration projects that CMS is supporting to provide funding to encourage change at the state and community levels including the state dual integration demonstrations, Alignment Initiatives, Money follows the Person, Independence at Home, Health Homes, Partnership and Transition initiatives, programs to strengthen primary care. The laundry list of new programs caused Susan Dentzer to ask if states were getting “demonstration fatigue”, something that I have wondered about while trying to remember the differences among the programs which often have same goals and objectives and similar focus to accomplishing the triple aim. Marsha Gold pointed out that while dual eligibles are of great policy interest, there isn’t a lot of timely data and there are only a small number of states and health plans that have a track record of successfully serving these high need populations. The article by Tricia Neuman and colleagues from the Kaiser Family Foundation recommends that initiatives to shift the duals into managed care plans need to be cautious and give time to develop infrastructure to serve patients with complex needs. State budgetary pressures are currently focused on a much more aggressive timetable.
Two other presentations caught my attention. Randy Brown revisited the Medicare Care Coordination demonstrations which were declared unsuccessful during the initial evaluation and found that 4 demonstrations were successful in reducing costs for high risk enrollees. The high risk enrollees had congestive heart failure, COPD, and coronary artery disease and one hospitalization in the prior year as a severity proxy and two or more hospitalizations with one or more of 12 chronic conditions. The study found that savings were only $123 per patient per month and thus case management fees must be below this level to produce net savings. Deborah Peikes looked at another Coordinated Care demonstration at Washington University and found that care coordination was successful after a major redesign eliminated the telephonic care management and focused in-person care management. Other successful ingredients were focus on managing transitions post hospital discharge, use of structured care plans, aggressive medication management and focus on higher-risk enrollees.