Mr. Jones had congestive heart failure, COPD and other chronic health problems. He was doing a poor job of taking his many prescribed medications. He made weekly visits to the Emergency Room. While he had low health literacy, a visit to his home by a medical student helped explain the impact of his health determinants. She discovered that taking his beta-blocker and aspirin each day was probably less important to him than having enough money to eat. A strict low sodium diet was unlikely when he bought his food at the gas station in walking distance.
With the emergence of accountable care organizations, episode-based payments and value-based care programs, addressing Mr. Jones health determinants is becoming essential. Studies show that healthcare only contributes 20% or less to overall health outcomes. There are not medical interventions for poor medication adherence, packaged gas station food or lack of transportation.
Mr. Jones is likely included in the denominator of a primary care physician MACRA value-based care program and a hospitals readmission penalty program for Heart Failure and COPD. While physicians and hospitals may use healthcare analytics to identify patients like Mr. Jones, the challenge is what do you do about it. It is very costly to send people into homes to do an assessment and medication reconciliation. Which patients do you provide rides to ensure they keep their appointments? Which patients do you provide nutrition support or help secure stable housing? A recent Health Affairs blog cites the lack of common definitions for interventions addressing social needs, thus making comparisons across populations and interventions difficult. We are asking physicians and healthcare systems to take on more risk, yet we lack clear evidence as to which interventions cost-effectively impact overall value (cost, experience, and health outcomes).
While we are getting better identifying high risk “PCP attributed” and “episode attributed” patients, the dilemma is what to do about it. Non-medical interventions must be carefully developed and implemented to ensure they are cost-effective in helping patients improve their overall health, reduce acute events and reduce the overall cost of the attributed patient population. If the programs are not cost effective, they will get abandoned and patients like Mr. Jones will continue to suffer with out of control chronic conditions. Mr. Jones’ attributed primary care physician and the episode attributed hospitals will be penalized until they figure this out.
Based on my experience working with advanced physicians and healthcare systems, there are 13 programs that work. What is missing from this overview is the cost effectiveness of these programs as compared to the health outcomes, cost reductions and patient quality of life. Many of these programs overlap and require coordination between them if they are implemented together.
1. Behavioral Health & Primary Care Integration – A study in JAMA found the use of integrated care teams was linked to lower care utilization and patients experiencing higher quality care. Medicare launched four new Collaborative Care Management (CoCM) payment codes January 1, 2017 to reimburse providers for these services.
2. Chronic Care Management – Patients with 2 or more chronic conditions in a coordinated care program reduced hospitalizations by 8–33%. Medicare introduced the Chronic Care Management (CCM) program in 2015. In 2017, they reduced the administrative requirements of CCM, added two new CCM codes, two new codes for Care Planning and two new codes for Cognitive Care Planning.
3. Episode Management – Hospitals drove down episode-based Medicare payments for lower extremity joint replacement by $1,166 by coordinating the hospital stay and post acute care. Medicare announced mandatory episode-based payments for heart attacks and coronary bypass surgeries in 98 geographic areas beginning July 1, 2017.
4. ER Case Management – Kaiser Permanente Northwest’s “navigators” within the ER reduced readmissions by 55% among the 254 patients by understanding patient needs and connecting them to the appropriate community resources.
5. Exercise & Nutrition – A small diabetes prevention program by the YMCA in Indianapolis has proven effective by using lifestyle interventions that includes a low-fat diet, exercise and 16 one-hour in-person meetings to assist in overall health improvement. Medicare believes this program can save $2,650 per participant over 15 months and will begin paying for it January 1, 2018.
6. Health Coaching – Studies have shown that health coaching improves the management of chronic diseases. Telephonic wellness coaching helps with weight loss. As much as 50% of the determinants of health outcomes are related to human behavior. Health coaches can help ensure people like Mr. Jones fills his prescriptions, takes his medications, gets the food for a low sodium diet and keeps his physician appointments.
7. High Need High Cost – Houston’s Patient Care Intervention Center program reduced patient costs in a program by 83% and hospital visits by 70%. Complex Care Initiative to help “superutilizers” in under served communities reduced hospitalizations by 27% and emergency department visits by 32%. An intensive care coordination program saved $14M in superuser costs.
8. Home Care – Mt. Sinai Hospital’s program delivers hospital-quality home care for patients who are at high risk for readmission cutting nearly 20% of the costs. Medical House Call Program reduced Medicare spending by 20 percent relative to expected spending for that population ($4,060 vs. $5,076).
9. Medical Home – Seniors that consistently see the same physician in an outpatient setting are 20% less likely to go to the emergency department. Primary Care Physicians deliver 20% lower overall healthcare costs and increase patient satisfaction. Health care ‘homes’ saves Minnesota $1 billion. Medicare and health insurers reimburse providers for this effort with the Annual Wellness Visits, Chronic Care Management and the 10 new Care Management Codes that began January 1, 2017.
10. Medication Management – Hospital readmission decreased 50% when pharmacists reviewed patients’ medication regimens and provided counseling during transitions from hospital to home. Prescription adherence among patients with multiple chronic conditions saved medical costs for patients with diabetes ($5,341), hypertension ($4,423) and high cholesterol ($2,081).
11. Palliative Care – Earlier palliative care consultation during hospital admission is associated with $1,312 lower cost of hospital stay for patients admitted with an advanced cancer diagnosis. Compassionate Care Program resulted in improving member satisfaction, an 81% decrease in inpatient days, and net savings of $12,000 per participating member.
12. Transitional Care Management – San Diego County program saved Medicare an estimated $13.8 million over a two-year period with a care transition program that sends nurses and social workers into homes to ensure transitions go smoothly, checking medications, making sure they know how to take them, walking through the house looking for things that could cause a fall, asking about caregivers to help with bathing and dressing. Medicare and health insurers reimburse providers for services with the Transitional Care Management care management codes.
13. Virtual Care – Mercy Hospital’s Virtual Care Center has led to a more than a 33% decrease in emergency room visits and hospitalizations. Banner Health launched its voluntary iCare telemedicine program that reduced per beneficiary costs by 27% while reducing hospitalizations by 45%.
See the Patient Well-Being Foundation site for more examples of What Works?