As policy-makers seek to slow the growth in Medicare spending, they have appropriately focused attention on beneficiaries with multiple chronic conditions.
Many care coordination and disease management programs designed to improve beneficiaries’ care and reduce their need for hospitalizations have been tested, but few have been successful. The six approaches practiced by care coordinators in at least three of the four programs were as follows: frequently meeting with patients or speaking with them by telephone; occasionally meeting with providers; acting as a communications hub for providers; delivering evidence-based education to patients; providing strong medication management; and providing timely and comprehensive transitional care after hospitalizations. When care management fees were included, the programs were essentially cost-neutral, but none of these programs generated net savings to Medicare.
The results of this study suggest that incorporating these approaches into medical homes, accountable care organizations, and other policy initiatives could reduce hospitalizations and improve patients’ lives. However, the approaches would reduce net costs only if care coordination fees were modest and organizations found cost-effective ways to deliver the interventions.