|Coordinated Care Programs For Medicare Beneficiaries Do Not Show Benefit
Only two of 15 Medicare programs designed to improve
care and costs for patients with chronic illnesses resulted in reduced
hospital admissions, and none of the programs generated net savings,
according to a study by researchers from the Mathematica Policy
Chronic illnesses pose a significant expense to the
Medicare program. The high expenditures generated by these
beneficiaries are driven primarily by hospital admissions and
readmissions, according to background information in the article.
Several factors appear to contribute to the high rate of hospitalizations, including:
- patients receiving inadequate counseling on diet, medication and self-care;
- not having ready access to medical help other than the emergency department; and
- poor communication between patients and physicians
Some studies have suggested that interventions to
address the barriers faced by chronically ill patients could reduce
avoidable hospitalizations and decrease Medicare expenditures.
To study whether care coordination improves the quality
of care and reduces Medicare expenditures, the Centers for Medicare and
Medicaid Services (CMS) in 2002 competitively awarded 15 demonstration
programs to various healthcare programs.
Deborah Peikes, and colleagues from Mathematica in
Princeton, N.J., analyzed the results from randomized controlled trials
of these 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 (usual care).
Hospitalizations, Medicare expenditures and some
quality-of-care outcomes were measured with claims data for 18,309
patients from patients’ enrollment through June 2006. A patient
survey 7-12 months after enrollment provided additional quality-of-care
measures. Nurses provided patient education and monitoring (mostly via
telephone) 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 researchers found that 13 of the 15 programs showed
no significant differences in hospitalizations. Mercy Medical Center,
in northwestern Iowa, significantly reduced hospitalizations by 17
percent, and Charlestown retirement community in Maryland had an
increase of 19 percent more hospitalizations.
None of the programs reduced regular Medicare expenditures.
Treatment group members in three programs (Health
Quality Partners [HQP, in Doylestown, Pa.], Georgetown, [a medical
center in Washington, D.C.] and Mercy) had monthly Medicare
expenditures less than the control group by 9 percent 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 percent 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
tosay they understood proper diet and exercise, or to state that they
were adhering to prescribed or recommended diet, exercise and
The authors add that a comparison of the two programs
with the most positive results with the other programs indicates there
were a number of noteworthy differences, including:
- higher rates of in-person contact per month per patient;
- treatment group members were significantly more
likely than control group members to report being taught how to take
- care coordinators for both HQP and Mercy worked
closely with local hospitals, which provided the programs with timely
information on patient hospitalizations and improved their potential to
manage transitions and reduce short-term readmissions; and
- care coordinators in both programs had frequent opportunities to interact informally with physicians.
"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.
The study was published in JAMA.
Address: Mathematica Policy Research Inc., P.O. Box 2392, Princeton, NJ 08543; (609) 799-0005, www.mathematica-mpr.com.