In the gap between our systems of public health and medical care lies a vast opportunity to better manage chronic diseases. Older adults with chronic diseases make up a large and growing proportion of our U.S. population and it is a group that accounts for a disproportionate share of health care expenditures and human suffering.
It is also a group whose needs seem poorly addressed by our existing health care system; on one hand needing more intensive or personalized interventions than our current public health model can support, on the other hand needing longer term risk factor management involving behavior change and ongoing support that goes beyond the practice of medicine. Both public health and medical care providers contribute much to the care of this population, but finding better ways to address its needs has been tough for both. To date, most new models and programs attempting to address this challenge that have undergone rigorous evaluation demonstrate little effect on the health outcomes, hospitalization rates, or health care service expenditures of this population. It may be that the “conceptual space” between public health and medical care offers an opportunity for more innovative and effective designs, to address what is, by historical standards, a relatively new, but dramatically growing challenge to health in the U.S.
A few prototypes that fill the gap between public health and medical care do exist. One of the most thoroughly evaluated is the Community-based Advanced Care Management program developed by Health Quality Partners (HQP), a nonprofit health care quality research and development team based in Doylestown, PA. This program is the only one of the fifteen programs tested in the Medicare Coordinated Care Demonstration (MCCD) that CMS is continuing to support. The model takes a person-centered approach to delivering a diverse portfolio of preventive, care management, and transition of care interventions in a convenient, uninterrupted, and supportive manner. The program is delivered in the community using nurse care managers who have frequent, ongoing, contact with participants and initiate collaboration with primary care medical providers, hospitals, and community services. The program has worked well collaborating with over 100 primary care offices of all sizes, shapes, and degrees of sophistication spread across a four county area in eastern Pennsylvania, including offices implementing the Patient-Centered Medical Home.
In the initial phase of the MCCD randomized, controlled trial, HQP enrolled low, moderate, and high risk chronically ill traditional Medicare beneficiaries; including individuals with hypertension, high cholesterol, COPD, diabetes, heart failure, or coronary heart disease without regard to their recent history of hospitalization or level of health care service utilization. The relatively low Medicare Part A & B average monthly expenditure of the control ($462) and treatment ($489) groups in the year prior to randomization confirm that this group overall was not selected for high cost.
In this population, HQP’s program was reported to have achieved budget neutrality for the Medicare program (Third Report to Congress) and in a separate unpublished report sponsored through a grant from CMS, the same third-party evaluators associated the program with a 26% decrease in all cause-mortality (p=0.036). Another analysis found that for HQP’s program both hospitalizations and expenditures were “approximately 11% lower for the treatment group” and that this was largely driven by results “in the program’s highest severity cases, comprising approximately 30% of the sample” in which “both differences were large (-29% for hospitalizations and -20% for expenditures) and statistically significant.” (JAMA Feb 11, 2009)
Under the 3 year extension recently granted to it by CMS, HQP will be targeting and enrolling a higher risk population; those with a diagnosis of heart failure, coronary heart disease, diabetes, or COPD and at least one hospitalization in the preceding year. This provides an opportunity to prospectively validate the findings from the first eight years of HQP’s MCCD results targeting this higher risk group (reduction of Part A & B expenditures by $487 per person per month/$5,844 per person per year; $372 PPPM/ $4,464 PPPY net after program fees).
As challenging as it has been to find promising prototypes of this kind, it will be even more challenging to find ways to expand their use on a large scale. It is estimated that at least 18% of current Medicare beneficiaries meet the new HQP enrollment criteria – a very large and diverse target group indeed. For programs like these to effectively serve a large population will require; 1. Thinking beyond the prevailing mental models of medical care delivery and public health, 2. Increasing the visibility of promising prototypes, so that others may be enlisted to use, support, and improve them, 3. Establishment of new forms and modes of organizational collaboration, so that organizations that are especially well suited to implement such models can be entrusted and supported to do so with strong support from multiple health care delivery systems in a region, 4. Tools and platforms to support the replication and reliability of such programs, in order to ensure that core program standards are implemented with fidelity to maintain effectiveness.
Despite the challenges ahead, it makes sense for the United States to aggressively pursue such opportunities. The savings in dollars and human suffering are likely to be enormous. The yawing gap between public health and medical care has been left unfilled for too long. Millions of older Americans with chronic diseases fall into that abyss everyday.
A few prototypes that fill the gap between public health and medical care do exist. One of the most thoroughly evaluated is the Community-based Advanced Care Management program developed by Health Quality Partners (HQP), a nonprofit health care quality research and development team based in Doylestown, PA. This program is the only one of the fifteen programs tested in the Medicare Coordinated Care Demonstration (MCCD) that CMS is continuing to support. The model takes a person-centered approach to delivering a diverse portfolio of preventive, care management, and transition of care interventions in a convenient, uninterrupted, and supportive manner. The program is delivered in the community using nurse care managers who have frequent, ongoing, contact with participants and initiate collaboration with primary care medical providers, hospitals, and community services. The program has worked well collaborating with over 100 primary care offices of all sizes, shapes, and degrees of sophistication spread across a four county area in eastern Pennsylvania, including offices implementing the Patient-Centered Medical Home.
In the initial phase of the MCCD randomized, controlled trial, HQP enrolled low, moderate, and high risk chronically ill traditional Medicare beneficiaries; including individuals with hypertension, high cholesterol, COPD, diabetes, heart failure, or coronary heart disease without regard to their recent history of hospitalization or level of health care service utilization. The relatively low Medicare Part A & B average monthly expenditure of the control ($462) and treatment ($489) groups in the year prior to randomization confirm that this group overall was not selected for high cost.
In this population, HQP’s program was reported to have achieved budget neutrality for the Medicare program (Third Report to Congress) and in a separate unpublished report sponsored through a grant from CMS, the same third-party evaluators associated the program with a 26% decrease in all cause-mortality (p=0.036). Another analysis found that for HQP’s program both hospitalizations and expenditures were “approximately 11% lower for the treatment group” and that this was largely driven by results “in the program’s highest severity cases, comprising approximately 30% of the sample” in which “both differences were large (-29% for hospitalizations and -20% for expenditures) and statistically significant.” (JAMA Feb 11, 2009)
Under the 3 year extension recently granted to it by CMS, HQP will be targeting and enrolling a higher risk population; those with a diagnosis of heart failure, coronary heart disease, diabetes, or COPD and at least one hospitalization in the preceding year. This provides an opportunity to prospectively validate the findings from the first eight years of HQP’s MCCD results targeting this higher risk group (reduction of Part A & B expenditures by $487 per person per month/$5,844 per person per year; $372 PPPM/ $4,464 PPPY net after program fees).
As challenging as it has been to find promising prototypes of this kind, it will be even more challenging to find ways to expand their use on a large scale. It is estimated that at least 18% of current Medicare beneficiaries meet the new HQP enrollment criteria – a very large and diverse target group indeed. For programs like these to effectively serve a large population will require; 1. Thinking beyond the prevailing mental models of medical care delivery and public health, 2. Increasing the visibility of promising prototypes, so that others may be enlisted to use, support, and improve them, 3. Establishment of new forms and modes of organizational collaboration, so that organizations that are especially well suited to implement such models can be entrusted and supported to do so with strong support from multiple health care delivery systems in a region, 4. Tools and platforms to support the replication and reliability of such programs, in order to ensure that core program standards are implemented with fidelity to maintain effectiveness.
Despite the challenges ahead, it makes sense for the United States to aggressively pursue such opportunities. The savings in dollars and human suffering are likely to be enormous. The yawing gap between public health and medical care has been left unfilled for too long. Millions of older Americans with chronic diseases fall into that abyss everyday.