the commonwealth fund chronic care initiatives to improve the medicare program stuart guterman...
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![Page 1: THE COMMONWEALTH FUND Chronic Care Initiatives to Improve the Medicare Program Stuart Guterman Director, Program on Medicare’s Future The Commonwealth](https://reader035.vdocuments.site/reader035/viewer/2022062421/56649f435503460f94c631b1/html5/thumbnails/1.jpg)
THE COMMONWEALTH
FUND
Chronic Care Initiatives toImprove the Medicare Program
Stuart GutermanDirector, Program on Medicare’s Future
The Commonwealth FundNational Congress on Health Reform
Washington, DCSeptember 22, 2006
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2THE
COMMONWEALTH FUND
Medicare Spending, 1970-2015Medicare Spending, 1970-2015
$16.3 $36.8$72.3
$111.0
$184.2$221.8
$336.4
$533.0
$753.5
$7.5
$0
$100
$200
$300
$400
$500
$600
$700
$800
1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
Sp
en
din
g (
in b
illi
on
s)
Note: Figures for 2010 and 2015 are projected.Source: 2008 Medicare Trustees’ Report.
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3THE
COMMONWEALTH FUND
Medicare Enrollment, 1970-2015Medicare Enrollment, 1970-2015
24.928.4
31.134.3
37.639.7
42.946.7
53.7
20.4
0
10
20
30
40
50
60
1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
En
roll
me
nt
(in
mil
lio
ns
)
Note: Figures for 2010 and 2015 are projected.Source: 2008 Medicare Trustees’ Report.
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4THE
COMMONWEALTH FUND
Medicare Costs per Beneficiary,Medicare Costs per Beneficiary,1970-20151970-2015
$642$1,285
$2,322$3,267
$4,953$5,653
$8,019
$12,163
$15,041
$356
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
Co
sts
pe
r B
en
efi
cia
ry
Note: Figures for 2010 and 2015 are projected.Source: 2008 Medicare Trustees’ Report.
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5THE
COMMONWEALTH FUND
Federal Spending on Medicare and Medicaid and Total Federal Spending on Medicare and Medicaid and Total Federal Spending as a Percentage of GDP, 1962-2082Federal Spending as a Percentage of GDP, 1962-2082
0
5
10
15
20
25
30
35
1962 1972 1982 1992 2002 2012 2022 2032 2042 2052 2062 2072 2082
Medic are and Medic aid T otal*
Percentage of GDP
*Total includes all federal non-interest spending.Note: Figures for 2007-2082 are projections.SOURCE: Congressional Budget Office. Budget Outlook.
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6THE
COMMONWEALTH FUND
Cost of Chronically IllCost of Chronically Ill
Medicare BeneficiariesMedicare Beneficiaries
• 78 percent of Medicare beneficiaries have at least 1 chronic condition, accounting for 99 percent of Medicare spending
• 20 percent of Medicare beneficiaries have at least 5 chronic conditions, accounting for 66 percent of Medicare spending
• These beneficiaries are treated by an average of 14 different physicians in a given year, and fill an average of 57 prescriptions
(SOURCE: The Johns Hopkins University, Partnership for Solutions.)
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7THE
COMMONWEALTH FUND
Caring for Chronically IllCaring for Chronically IllMedicare BeneficiariesMedicare Beneficiaries
• Heavily burdened by their illnesses
• Neither fee-for-service Medicare nor Medicare Advantage is currently configured to provide adequate care for these beneficiaries
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8THE
COMMONWEALTH FUND
Caring for Chronically IllCaring for Chronically IllMedicare BeneficiariesMedicare Beneficiaries
• Fee-for-service Medicare:--emphasis on provision of services by individual providers--centered on single encounter or spell of illness--no incentive for coordinated care needed by the chronically ill
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9THE
COMMONWEALTH FUND
Caring for Chronically IllCaring for Chronically IllMedicare BeneficiariesMedicare Beneficiaries
• Medicare Advantage:
--should be an appropriate environment for coordinated care
--but current payment system based mostly on costliness of average beneficiary
--until the MMA, rules limited ability to specialize in specific types of patients
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10THE
COMMONWEALTH FUND
Implications for MedicareImplications for Medicare
• We need to find better ways to coordinate care for Medicare beneficiaries with chronic illnesses
• There’s a lot of money spent on these beneficiaries that can be better used to encourage appropriate care
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11THE
COMMONWEALTH FUND
ChallengesChallenges
• Need to retool data system
• Decentralized program administration
• In fee-for-service Medicare, drug benefit separate from medical benefit
• Difficulty communicating with beneficiaries
• Difficulty integrating physicians into process
• Pressure to provide quick payoff
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12THE
COMMONWEALTH FUND
ObjectivesObjectives
• Improve access to needed and appropriate care
• Improve coordination of care• Improve physician performance by making
them more involved and responsive to patient needs
• Improve patients’ ability to become involved in health care decisions and participate in their own care
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13THE
COMMONWEALTH FUND
Medicare InitiativesMedicare Initiatives• Medicare Case Management Demonstration
– 1st Medicare chronic care initiative (October 1993-November 1995)
– 3 sites– Focused on increased education regarding proper patient
monitoring, management of target condition– Low level of enthusiasm from beneficiaries, due to lack of
physician involvement or sufficiently focused interventions
• Medicare Coordinated Care Demonstration– Mandated in BBA (enrollment began in April 2002)– 15 sites– Focused on complex chronic conditions– 21,000 enrollees (60 percent at 5 sites)– Recruitment a challenge—most successful programs had close
ties to providers– Well received by participants, but short on savings
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14THE
COMMONWEALTH FUND
Medicare InitiativesMedicare Initiatives• Medicare Disease Management Demonstration
– Mandated in BIPA (began in Spring 2004)– 3 sites, up to 30,000 beneficiaries– Sites fully at risk– Disease management and prescription drugs– Sites encountered greater than anticipated difficulties identifying
and enrolling beneficiaries—demonstration discontinued before completion
• Medicare Health Support Pilot– Mandated in MMA (began in August 2005)– 8 sites, 160,000 beneficiaries– Sites at risk for fee (5% savings initially required)– Focused on diabetes, CHF– Opt-out enrollment model– Secretary given explicit authority to expand scope if initial data
indicated savings and/or quality improvement– Sites failed to achieve savings, project ended
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15THE
COMMONWEALTH FUND
Medicare InitiativesMedicare Initiatives• Special Needs Plans (Medicare Advantage)
– Mandated in MMA (began in 2006)– Focus on individuals with special needs: dual-eligibles, chronic
condition, institutionalized– Paid like other MA plans, but permitted to target enrollment– (As of 09/08) 770 plans (440 dual-eligible), 1.3 million enrollees
(0.9 million dual-eligible)– Questions have been raised about whether SNPs are, indeed,
special; provisions in MIPPA strengthen requirements for dual-eligible plans
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16THE
COMMONWEALTH FUND
Where Does That Leave Us?Where Does That Leave Us?
• Disappointing results
• We haven’t found the right model yet
• Band-aids on a broken system?
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17THE
COMMONWEALTH FUND
Provider-Driven ModelsProvider-Driven Models
• Physician group practice demonstration– FFS payment + shared savings/ performance
bonus
• Medicare care management performance – Physician practice-based care management
• Care management demonstration for high-cost beneficiaries– Provider-driven alternative to MHS
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18THE
COMMONWEALTH FUND
The Healthcare Delivery SystemThe Healthcare Delivery System
Still:
• Acute care focused
• Fragmented
• Modeled on medical management
• Reactive system
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19THE
COMMONWEALTH FUND
Value-Based Purchasing Value-Based Purchasing StrategiesStrategies
• System efficiencies across providers– Care coordination – Managing transitions across settings
• Shared clinical information – Fewer duplicative tests and procedures
• Improved processes and outcomes– Increased guideline compliance
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20THE
COMMONWEALTH FUND
Value-Based Purchasing Value-Based Purchasing StrategiesStrategies
• Patient education– Self-care support
• Reduce avoidable hospital admissions, re-admissions, emergency room visits
• Substitute outpatient for inpatient services– Less invasive procedures for more invasive procedures
• Reduced lengths of stay
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21THE
COMMONWEALTH FUND
Medicare Health Care Quality Medicare Health Care Quality (MHCQ) Demonstration(MHCQ) Demonstration
• System redesign
• Payment models incorporating incentives to improve quality and safety of care and efficiency– Best practice guidelines– Reduced scientific uncertainty– Shared decision making– Cultural competence
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22THE
COMMONWEALTH FUND
ConclusionsConclusions
• Still looking for right model
• Can’t give up—too much riding on being able to improve, for both the program and, most importantly, for its beneficiaries
• Look at in the context of broader reform of the health care delivery system