Another large, well-designed (case control) study of intensive intervention for high risk patients was reported by Centers for Medicare and Medicaid Studies in this week’s JAMA. The demonstration project covered over 18,000 patients in 15 demonstration projects and was evaluated by Mathematica Policy Research. While many of the programs lowered hospitalizations and overall medical cost, none showed net savings after accounting for the program cost. (Harvard full text link)
The programs most likely to come close to covering their costs had a few characteristics
1) 1. The nurse coaching interventions were done in-person
2) 2. The nurse coach was tightly integrated with the physician’s office, often seeing patients at the office
3) 3. The intervention patients were very high cost in the first place
4) 4. The programs had the highest emphasis on patient education.
The researchers note that these learnings might help design better interventions in the future. The two most successful programs will be continued, although CMS fees were cut dramatically in one case, so the program will likely require subsidies from the provider organization.
The January-February issue of Health Affairs reviews all the Medicare demonstration projects on disease management since 1999 (not including the new JAMA article). The results are really depressing. Many of the programs worked – they made care better – but none saved enough to cover the program implementation cost.
An unconnected (but very much related) editorial in JAMA points out that little in health care actually saves money, and wonders why we don’t want to cover disease prevention programs when their cost effectiveness is equivalent to (or better than) the cost effectiveness of many disease treatments. Author Steven Woolf’s conclusion: “Throughout health care, the spending crisis requires a comprehensive search for ways to shift spending from services of dubious economic value to those with high cost-effectiveness or net savings.” (Harvard Link)
