Next Steps: How Can Medicare Accelerate The Pace Of Improving Chronic Care?

Abstract

David Bott and colleagues report little success so far in demonstrations and pilot programs undertaken since 1999 to improve chronic disease management in the traditional Medicare program. The findings presented are highly generalized. To accelerate learning and progress, the Centers for Medicare and Medicaid Services (CMS) should expedite release of program-specific evaluations and data for external review. In addition, experience from the quality improvement field suggests that a new approach to program development would be beneficial, featuring intensified collaboration and data exchange to facilitate rapid program improvement, and application of a broader set of scientific methods than are used in clinical trials to gauge results. [Health Affairs 28, no. 1 (2009): 99-102; 10.1377/hlthaff.28.1.99] I m p r o v i n g c h r o n i c disease management is an important priority to make the Medicare fee-for-service (FFS) program more effective and efficient. More than half of Medicare beneficiaries have multiple chronic conditions, and these beneficiaries account for 96 percent of annual Medicare spending ($418 billion in 2007). 1 U.S. adults receive only about 56 percent of recommended chronic care. 2 Coordination of care is a wellrecognized challenge. 3 The medical care and self-care of Medicare beneficiaries are often very complicated. On average, Medicare beneficiaries visit seven different physicians and fill more than twenty prescriptions per year. 4 David Bott and colleagues describe seven initiatives that the Centers for Medicare and Medicaid Services (CMS) has undertaken since 1999 to improve chronic disease management under FFS Medicare. 5 The report is not encouraging. The authors note overall disappointing results to date with respect to cost savings and quality improvement. Of thirtyfive programs undertaken, twenty-eight have ended. The agency is continuing seven that it believes may have some potential and is developing a new demonstration to test the concept of patient-centered medical homes. This new demonstration may also fall short of expectations. As Robert Berenson and colleagues wrote recently, "It would not be the first time that a promising policy idea was judged a failure because of premature promotion. Steps To Accelerate Learning And ProgressWhat are the primary lessons from the recent Medicare programs that can increase the probability of future success? The summary by Bott and colleagues provides few guideposts. It lumps together programs with diverse target populations, outreach and engagement methods, program structures, interventions, financial arrangements, time frames, evaluations, and outcomes. These variations are noted but not examined. The primary focus of the paper is on whether or not the programs met or approached overall budget-neutrality. Five premises for disease management are described, but program evaluation results are not provided to substantiate or refute those premises.The summary indicates that the CMS has evidence to support the findings presented, b...

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