All in all, it's bound to disappoint employers, who continually quest for lower health care costs and improved health outcomes.
But, in a telephone conversation with EBN, researcher Randall Brown of Mathematica Policy Research says there's no sense in getting overly dejected about the results of his firm's analysis on care coordination.
"It's not a panacea, and it's not broadly effective, but don't throw the baby out with the bath water," he says. "There are some efficient programs; it's just not easy to do these types of programs."
Mathematica started looking at the issue of care coordination when the Centers for Medicaid and Medicare Studies had the idea that if care coordination could save money for private employers and other providers, why couldn't it work for the people on the public rolls?
At first, Brown says they hired Mathematica to just scan the literature to find what was in the market. Turns out there wasn't much to scan, so Mathematica set up its research project, whereby it studied patients in 15 care coordination models between April 2002 and June 2005. The results of that effort were published in the February issue of the Journal for the American Medical Association.
Brown says there is much for employers to learn from the research on Medicare patients.
For one thing, "it's really hard to reduce hospitalizations for people that are pretty high risk."
For another, "these kinds of programs are really only going to help a lot for people who have congestive heart failure, severe diabetes, the things that do tend to land you in the hospital. That's where all the costs are anyway."
EBN: So what did you learn? What works when it comes to coordinating care for the chronically ill in hopes of reducing hospitalization costs?
Brown: The target population, you need to get people at pretty high risk of a hospitalization. [And you] need to have high in-person contacts.
EBN: What does that look like from a program design standpoint?
Brown: The collocation of the nurse and the care coordinators so that the nurse actually knew the primary care physician and trusted them.
Also, cases where nurses were in close proximity to the patient's primary care physicians or they went out of their way to establish those relationships.
In addition to collocation of care coordinators and physicians, trying to link up all the physician's patients with a single care coordinator so they weren't getting calls from a half a dozen care coordinators [is effective].
If those [calls] are always coming from the same care nurse, that kind of bond and trust between physician and nurse is a lot easier to establish than if they have five patients in the program and it's five different nurses calling them up.
EBN: While you don't think reaction to this research should be overly negative, would you admit it's logical for it to be disappointing, given the industry's continuous hunt for a "silver bullet" to fell the health care cost beast?
Brown: What you're doing is trying to change physician behavior, trying to change patient behavior, and neither one of them is very easy to do.
We keep looking for [the solution]. It's managed care. It's disease management. Now, it's going to be medical homes. That's what we've tried to say, there are lessons in this [research] for medical homes. That's what medical homes are trying to do — coordinate this care.
EBN: What else should benefit professionals take away from this research?
Brown: There are four ways you can help people stay out of the hospital.
One of them is you can get the patient to adhere to their recommended diets and medications better. That's the nurse working with the patient and patient's family.
You can let the physician know when their patient is having a problem or when there is some feature of their care that is not consistent with the guidelines.
The third thing is the nurse contacting the patient outside of office visits, monitoring the patient, basically.
The patient doesn't want to call the doctor, they don't want to bother the doctor because they are having this problem. If the nurse calls them up two or three times a month or sees them, then they say how they are doing. The nurse then is able to assist with whether the patient should really get in to see the doctor or get medication changed.
That's what [Mercy Medical Center] said was responsible for their effect — they were able to identify problems quickly.
Nurses had standing orders from their physicians, which allowed them to tell the patient to [give medical instructions]. The physician knew and trusted the nurses, so they felt comfortable giving them the authority to make those recommended changes when they are dealing with the patient.
EBN: Does this research tell employers anything about some of the other areas they have been pursuing to help control costs — disease management, wellness and the like?
Brown: I think they should take away from this that if a disease management vendor comes in and says they are going to do this telephonic thing and it's going to save them 30% on their health care costs, [employers] should say, "Prove it — with hard evidence."
They get disease management programs peddled to them all the time. I would say demand to see some serious evidence for this and have it looked at by somebody that is capable of evaluating it, because a lot of this stuff is very self-serving.
EBN:You mean some employers may not be equipped to judge these programs? Where should they go for help?
Brown: They could call up a place like ours or other research organizations. They could call up an academic health person. Check on the Web. It's worth their while.
EBN: That gives employers some idea of what to watch out for. What are some hallmarks of a properly constructed plan?
Brown: Really target the seriously chronically ill. What you really want to do is focus in. You want to get a program that's really going to hone in on the people that are really high risk, because that small proportion of their employees are going to account for a huge portion of their costs.
EBN: What about employers' interest and appetite for wellness programs, which seek to cover everyone, or as many people as possible?
Brown: It depends what your goal is. If your goal is to have a healthy workforce that doesn't miss many days in the office, then wellness programs are great programs.
[But] if you are trying to save dollars in terms of medical cost, it's not going to happen there for the most part.
It's also not going to happen in the short run. Having a program like weight loss — those are great and will save you money because patients will recover more quickly [and] be less sickly.
Exercise programs, all those types of things, are great programs to have and probably do save employers money, because they reduce absenteeism. [But] if you are really looking to save big dollars, you have to go for the chronically ill.
Not-so-great expectations
Mathematica's research on the impact of better coordinated hospital care is likely to reset expectations about the money these programs can save the government, employers and individuals.
Here's a quick overview of what the group learned about the cost-saving benefits of more coordinated medical care for the chronically ill and its impact on hospitalization costs.
>> 13 of the 15 programs studied showed no significant differences in hospitalizations.
>> Iowa's Mercy Medical Center was the lone participant to reduce hospitalizations, recording 17% less than the control group.
>> Maryland's Charlestown Hospital actually recorded 19% more hospitalizations than the control group.
The conclusion? Care coordination programs lacking a strong transitional care component aren't likely to save a lot of money. Programs with lots of face-time built in that focus on moderate to severe patients can be cost-neutral and improve some aspects of care.
