Evidence Based Care Coordination: Can it Work in Medicare (Yes) Kenneth E.

Thorpe Emory University and Partnership to Fight Chronic Disease

January 24, 2012

The Congressional Budget Office has recently provided another summary of the lessons learned from the Medicare care coordination demonstrations (http://cbo.gov/doc.cfm?index=12663). Coverage of the CBO study have, in several cases, inaccurately stated that care coordination programs do not work to lower costs and cited the CBO study as support. This is a misreading of the report and indeed the lessons learned from the demonstrations. In fact, the evidence base of how to build successful, cost-saving care coordination efforts gleaned from Medicare models in the demonstrations (of which there were success)1 and other public and private efforts is solid and growing. It is important to keep in mind that Medicare demonstrations are planned and executed to examine how different program designs affect outcomes. The six Medicare disease management and care coordination demonstrations examined in the CBO report involved a wide range of program designs, making general conclusions impossible. Most of the approaches examined did not appear particularly effective, but some were. Instead of simply concluding that nothing worked, as some reports have done, a reasonable approach to optimizing the knowledge gained would be to examine the key design features of the successful programs and build on them and learn what to change or avoid from the less successful ones. The false conclusion that care coordination will not work is directly contradicted in the CBO report itself. In addition to including programs that did reduce costs, the CBO report outlines the key design features of care coordination (use of transitional care, close integration of care teams and the
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practice) that do work and are helpful at attaining the goals of improved quality and lower spending. Understanding how the methods used in designing some demonstrations also can have a significant effect on interpreting an efforts outcomes. In fact, methodological issues can significantly limit the conclusions that may be drawn from past demonstrations. For instance, in the Medicare Health Support Pilot, CMS used an intent to treat approach. This means the experimental group was viewed as treated even if they did not participate. In several of the pilots, those that did not participate were sicker, higher cost patients. When you compare those patients actually treated in the experimental group to the controls (after making the appropriate statistical adjustments), there were significant overall cost savingson the order of 15 percent.2 Methodological issues should not stand in the way of gleaning valuable lessons on what works when people engage and actually receive the services tested. A second major issue with the CBO report itself is that they limited their data to CMS-based demonstrations. CMS-based demonstrations are only a small subset of randomized trials being conducted nationally to assess the impact of care coordination on costs and quality. For example, a large randomized trial was conducted by Health Dialog published in the New England Journal of Medicine was not included.3 Using telephone based health coaching to work with a large population (more than 174,000) of patients, this recent randomized trial showed that total health care spending was 3.6 percent lower in the treatment group (yielding about a 3 percent net savings after accounting for the cost of the intervention). This single component of care coordination alone reduced hospitalizations in the trial by 10 percent and total spending by more than 3 percent. Managing transitions between care settings and providers is an important element of care coordination. There are several published randomized trials showing that well designed transitional care reduces hospitals readmissions reduces total Medicare spending and improves

health care outcomes. Just the use of transitional care alone throughout traditional Medicare could reduce Medicare spending by $125 Billion over the next decade.4

A meta-analysis of 18 studies (from eight countries) showed that comprehensive discharge planning coupled with post-discharge support for those hospitalized due to congestive heart failure resulted in reduced readmissions of nearly 25%.5 More recent randomized trials from the University of Pennsylvania and Colorado have showed that nurse-led transition care programs can reduce preventable readmissions by up to 56%.6, 7

Three randomized trials have tested and refined the transitional care model (TCM). The TCM has consistently demonstrated through these trials to improve health outcomes. reduce hospital readmissions (43 percent lower at 6 weeks post discharge and 50 percent 26 weeks post discharge) and lower total Medicare spending.

Another randomized trial of another transitional care model outlined by Eric Coleman using nurse transition coaches produced lower rates of readmission and a 20 percent reduction in hospital spending.8 Appropriate use of prescription drugs is a key element of effective management of chronically ill patients, and several studies have shown that higher rates of medication adherence also reduce spending. For example, a recent CVS Caremark study found that patients with higher medication adherence had much lower medical spending, ranging from $1,860 per year for patients with hyperlipidemia to more than $8,880 for congestive heart failure patients.9 Several studies demonstrate that by increasing medication adherence through proven strategies such as patient education, simplified dosing schedules, additional open clinic hours, and improved communication between providers and patients significant savings can be
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achieved alongside improved clinical outcomes.10

In fact, many large, integrated group

practices (e.g., Geisinger, GroupHealth, and Community Care of NC) have already implemented programs to improve medication adherence among patients with much success. 11 Medication therapy management is provided by a pharmacist working with the patient (and care team or plan) to assure the safe and effective use of medication to achieve the targeted health care outcome.12 This includes issues of dosage, interactions among drugs, filling and refilling medications among other functions. For example, a 10-year study at large integrated health system that installed evidence-based medication therapy management found the effort generated a system-wide ROI of 1.29.13

The CBO study includes none of these references further making reports that care coordination efforts do not work spurious at best.

CONCLUSIONS What the CMS demonstrations and the wide range of other randomized trials show is that welldesigned care coordination works. Modeling Medicare reforms on the lessons learned as to what works could have a profound, positive effect on both healthcare costs and the health status of people with Medicare. To begin making an immediate difference, Medicare could adopt greater care coordination by introducing health teams into the program using section 3502 of the Affordable Care Act. This section of the ACA outlines the functions the teams would perform and includes all the evidence-based ones outlined above. Deploying the teams nationally to perform health coaching, transitional care, medication management, care coordination and other functions all closely integrated with a provider practice according to the evidence- will improve outcomes at lower costs.

NOTES
1

Brown, R. The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illness. Mathematica Policy Research; March 2009
2

Atherly, AA, Thorpe KE. Analysis of the Treatment Effect of Healthways Medicare Support Phase 1 Pilot on Medicare Costs. Population Health Management, 2011 14(supplement 1)
3

Wennberg DE, Marr A, Lang L, OMalley S, Bennett G, A Randomized Trial of a Telephone Care-Management Strategy, 2010 New England Journal of Medicine 363(13): 1245-55
4 5

See http://www.transitionalcare.info/ToolQual-1801.html Epstein AM. Revisiting Admissions Changing the Incentives for Shared Accountability. New England Journal of Medicine 2009, April 2, 2009;360(14)1457-59. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with post discharge support for older patients with congestive heart failure: a meta-analysis. Journal of the American Medical Association 2004;291:1358-67.
6

Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, J.S. Schwartz. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. Journal of the American Geriatrics Society. May 2004;52:675-84. See also: Naylor M, Brooten D, Jones R, et al. Comprehensive discharge planning for the hospitalized elderly. Annals of Internal Medicine 1994;120(June):999-1006. Naylor MD, Brooten DA, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders. Journal of the American Medical Association 1999;281:613-20. Naylor MD. Transitional care of older adults. Annual Review of Nursing Research. 2003;20:127-47.
7

Coleman EA, Parry C, Chalmers S, Min S-j. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine. 2006 September 25, 2006;166(17):1822-8. See also: Coleman EA, Smith JD, Frank JC, Min S-J, Parry C, Kramer AM. Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention. Journal of the American Geriatrics Society. 2004;52(11):1817-25. Parry C, Coleman EA, Smith JD, Frank J, Kramer AM. The Care Transitions Intervention: A Patient-Centered Approach to Ensuring Effective Transfers Between Sites of Geriatric Care. Home Health Care Services Quarterly. 2003;22(3):1-17. Parry C, Mahoney E, Chalmers SA, Coleman EA. Assessing the Quality of Transitional Care: Further Applications of the Care Transitions Measure. Medical Care. 2008 March;46(3):317-22. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauley MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620.

Naylor MD, Brooten DA, Campell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684
8

Coleman EA, et al. The Care Transitions Intervention: Results of a Randomized Trial. Arch Intern Med 2006; 166: 1822-1828
9

Roebuck MC, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication Adherence Leads to Lower Health Care Use and Costs Despite Increased Drug Spending. Health Affairs 2011; 30(1): 91-9
10

Meyer J, Smith B. Chronic Disease Management: Evidence of Predictable Savings. Washington, DC: Health Management Associates; 2008. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost. Medical Care 2005, June;43(6):521-30. McDonald HP, Garg AX, Haynes RB. Interventions to Enhance Patient Adherence to Medication Prescriptions: Scientific Review. Journal of the American Medical Association. 2002 December 11, 2002;288(22):2868-79. Osterberg L, Blaschke T. Adherence to Medication. New England Journal of Medicine. 2005 August 4, 2005;353(5):487-97. Kripani S, Yao X, Haynes B, Interventions to Enhance Medication Adherence in Chronic Medical Conditions: A Systematic Review. Archives of Internal Medicine 2007; vol. 167:550. Pradler C, Benzt L, Spire B, Tourette-Turgis C, Morin M, Souville M, Rebillion M, Fuzibet JG, Pesce A, Dellamonica P, Moatti JP, Efficacy of an Educational and Counseling Intervention on Adherence to Highly Active Antiretroviral Therapy: French Prospective Controlled Study. HIV Clinical Trials 2003;4(2):121-131.
11

D. M. Cutler, W. Everett, Thinking Outside the Pillbox Medication Adherence as a Priority for Health Care Reform. New England Journal of Medicine. 2010 April 29, 2010;362(17): 1553-55.
12

Specific evidence based approach to medication management and evidence of overall savings summarized at http://www.pcpcc.net/files/medmanagement.pdf.
13

Ramalho de Oliveira, D et al. Medication Therapy Management: 10 Years of Experience in a Large Integrated Health System. Journal of Managed Care Pharmacy, 2010: 16(3): 185-195