The Collaborative Forum

Vince’s post begs the question: “So…if one were to redesign the MMHD to fulfill the potential for both improving care quality (through access to an appropriate “Medical Home”) while simultaneously reducing healthcare costs, where might we start?”

Vince points us in the right direction in his post, calling our attention to the work of Randall Brown in his report of another CMS demonstration, the Care Coordination Demonstration. Brown points out two key observations:

1. Care Coordination, to save money, must start with the “right” population target; and,

2. Care Coordination interventions can only save money if they don’t COST more than about $120 per participant per month (the amount likely to be saved from a well-designed intervention).

In other words, the solution to the dilemma has two aspects: 1. FOCUS and 2. EXECUTION.

1. Focus

If the MMHD, or any other care management strategy for that matter, is to succeed, the initial targeting of the “right” population is critical. The MMHD, as currently conceived, does not achieve anything close to adequate targeting for its “interventions” (we’ll get to the “interventions” in a minute). The focus on chronic disease IS the right focus, I would argue, but if you can be enrolled as a patient into the MMHD with one chronic disease, and moderate HCC (Hierarchical condition code) risk score of <1.6, there won’t likely be sufficient “cost avoidance” to justify the intervention expense. Why is that?

According to the Congressional Budget Office May 2005 report: High Cost Medicare Beneficiaries, individuals with MULTIPLE chronic conditions or who had been hospitalized would clearly justify a Medical Home. Indeed, according to the report, if you were one of the bottom 50 percent of Medicare beneficiaries by annual expense, the average annual Medicare expenditure was only $550.

On the other hand, if you were one of the unfortunate beneficiaries who fit the profile of having multiple chronic conditions or were hospitalized, there is a clear opportunity for improvement: even the LEAST expensive member of this group cost $6200 per year. Further, if you had multiple chronic conditions, your costs tended to stay high over a subsequent four year period.

So…were the MMHD to focus on that portion of the Medicare population who had multiple chronic conditions and/or one chronic condition but a history of hospitalization, not only would a significant savings opportunity exist, it would even justify an intervention expense of the Tier 2 Advanced Medical Home, while still likely to demonstrate cost savings to CMS. This group constitutes the TOP 25 percent of Medicare spenders, not 86 percent as currently targeted by the MMHD-style Medical Home.

Another way to consider the target population would be to look at the high prevalence and high cost chronic conditions that would likely qualify as cost savings targets. Here, more than 75 percent of High Cost Medicare beneficiaries (75 percent of the top 25 percent) have one or more of a short list of chronic conditions. These include the “usual suspects” of CHF, COPD and diabetes. In fact, according to the report, of the top 25 percent, these conditions are present 30 percent of the time.

Our direct experience with another CMS demonstration, the Physician Group Practice Demonstration suggests that CHF, COPD and high risk diabetes could constitute THE FOCUS for a suite of Medical Home interventions. See the table below:  

Source: Internal Analysis of RTI International Report, Physician Group Practice Demonstration Performance. Year 3 Results. April 2009.

So, just to do the math, if the MMHD targeted only those with CHF, COPD, and diabetes, this group would represent the majority of the high cost Medicare population:

• all falling well within the top 25 percent of Medicare expenditure;

• all having 2x-4x the annual cost burden of the lowest 75 percent of Medicare per patient annual expense; and

• all having a high probability of avoidable cost just due to hospitalizations!

2. Execution

Of course, targeting the Medical Home properly is only part of the challenge. Leveraging the “right interventions” against the cost savings opportunities represents the other part of the challenge. As currently structured, the Medical Home, even in its most “advanced” forms, may fall short on executing. Why?

The right interventions targeted at the right opportunities can and have worked in a Medical Home model. But the tricks are considerable, and the “execution” wins or loses in the detail.

For example, as currently conceived, the Medical Home will have disease registry functionality. This is a necessity, but arguably not sufficient, part of a Medical Home intervention suite.

The Medical Home will have care coordination, another necessary component of the right interventions. But care coordination can be a bit like a hair cut; who is doing it determines whether or not you’ll be pleased with the result. I’d argue that physicians, while good at overseeing care coordination, are not the best care coordinators. Nurses, pharmacists, and other physician extenders are.

So what ARE the key operational components to actually reducing wholesale costs in a high cost population of Medicare beneficiaries?

• Care Coordinators – in a ratio of 200 chronic care patients to one coordinator, and following a set of standard treatment protocols and standing orders, trained in behavioral and motivational interviewing;

• Physician Oversight – by a primary care physician, or a specialist who agrees to the role. Part of the “job description” is the requirement to adhere to standard treatment protocols and be available for care coordinator management “exceptions”;

• Disease Registry functionality – no, not an EMR or e-prescribing. Those are “nice to haves” but will not allow targeting of the interventions that will reduce unnecessary hospitalizations; and,

• REMOTE PATIENT MONITORING TECHNOLOGIES – daily self-care support and clinical deterioration monitoring WILL and DOES avoid 20-60 percent of hospitalizations when used in large scale populations with CHF, COPD and high risk diabetes.

The recently published experience with a Medical Home model, staffed with care coordinators, overseen by primary care physicians, and armed with disease registry and remote patient monitoring functionality confirms our experience in other settings like the CMS PGP demonstration, and other medical home pilots in smaller settings. See Darkins, A, et al: Telemed JE Health, December 2008 for more details.

And guess what? This full suite of interventions, including technology, labor costs and physician reimbursement, can be implemented for about the same monthly cost as the currently proposed Tier II Advanced Medical Home! In other words, this version of the Medical Home works within the cost parameters articulated by Brown in his analysis as necessary to assure cost savings.

Tags: Care coordination, Care management, CMS, EMR, Medical Home, Medicare, Remote Patient Monitoring