WASHINGTON — Medicare has a number of demonstration projects underway to help chronically ill beneficiaries get better care, and is developing more, Linda Magno said at a meeting of the Practicing Physicians Advisory Council.
Beneficiaries with chronic illnesses are a significant part of the program's budget, said Ms. Magno, director of Medicare demonstrations for the Centers for Medicare and Medicaid Services (CMS). Although beneficiaries with five or more chronic conditions make up only 20% of all beneficiaries, they account for two-thirds of Medicare spending, she noted.
With all of the spending on this population, opportunities exist for making sure the money is spent more efficiently, Ms. Magno said. Currently, CMS has three demonstration projects going in chronic care:
▸ Medicare Coordinated Care Demonstration. In this project, which was mandated by the Balanced Budget Act of 1997, the agency is examining various care coordination models that “improve quality of services to chronically ill beneficiaries and reduce Medicare expenditures.” The Health and Human Services Secretary has discretion to continue or expand projects, Ms. Magno said, adding that currently 11 sites—a mix of urban and rural hospitals and long-term care facilities—are involved in this demonstration. Interventions include patient and provider education, prescription drug management, case management, and disease management.
▸ Care Management for High-Cost Beneficiaries. This 3-year, six-site project began last October; the last site was launched in June, Ms. Magno said. The provider groups in the demonstration put their Medicare reimbursement at risk in exchange for guaranteeing a 5% cost savings in caring for the high-cost beneficiaries involved. Services provided include physician and nurse home visits, in-home monitoring devices, electronic medical records, caregiver support, patient education, preventive care reminders, transportation services, and 24-hour nurse telephone lines.
▸ Physician Group Practice Demonstration. This demonstration was mandated in the Benefits Improvement and Protection Act of 2000, and involves giving additional payments to providers based on practice efficiency and improved management of chronically ill patients. Participants include 10 very large multispecialty group practices nationwide with a total of more than 5,000 physicians, who care for more than 200,000 Medicare beneficiaries. The project focuses on patients with diabetes, heart failure, coronary artery disease, and hypertension. Enrollment has been “very slow,” Ms. Magno said.
Two more chronic disease management demonstrations are in various stages of development. The Medicare Care Management Performance Demonstration, for example, is a pay-for-performance program that will reward physicians financially for achieving quality benchmarks for chronically ill patients and for using health information technology, including using it to report quality measures electronically. This project, which is in final review, will be implemented in Arkansas, California, Massachusetts, and Utah, Ms. Magno said.
Also in development is the Medicare Health Care Quality Demonstration. This involves using payment models that give incentives for improving the quality, safety, and efficiency of care, and incorporating things like best practice guidelines, shared decision making, and cultural competence into the practice. “This [project] is really a provider-driven opportunity to redesign the delivery system, as opposed to something externally imposed through insurers and other payers,” she said. “The goal is to achieve projects designed to implement Institute of Medicine aims for improvement” known as the STEEEP principles—safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness.
PPAC member Dr. Carlos Hamilton suggested that many of the beneficiaries on whom Medicare spends more than $25,000 per year are probably in the last year of their lives, and that needless “ping-ponging” occurs when they are sent from the nursing home to the emergency department to the intensive care unit for, say, a case of sepsis. “Addressing concerns about palliative care and end-of-life issues is critical if you're ever going to address the cost factors in terms of the overall health care system. If you can keep people from being transferred from the nursing home to the emergency [department] and the ICU in the middle of the night, you'll probably save a billion dollars right there.”
The other issue, said Dr. Hamilton, an endocrinologist who is executive vice president for external affairs at the University of Texas, Houston, has to do with lack of coordination of care for chronically ill patients. “The primary care physician has been reduced to such a role in the system that nobody wants to [coordinate care] any more, and those that do quickly find out they can't afford to do that very effectively. So the system needs to strengthen the role of primary care physicians.”
Ms. Magno noted that the “Welcome to Medicare” visit that new beneficiaries receive was meant to allow physicians to do a patient risk assessment and discuss preventive measures. In addition, she said that CMS is considering a Senior Risk Reduction Demonstration to test the use of health risk assessments for Medicare beneficiaries under age 70.