Two decades worth of experimenting with disease management and value-based purchasing in Medicare has not reduced spending and, in same cases, increased outlays, the Congressional Budget Office reported in late January.
The CBO studied 10 major demonstration projects — six in disease management, four in value-based purchasing. The CBO noted that in nearly every disease management/care coordination project, spending was either unchanged or increased. Results for value-based purchasing were mixed. A bundled payment demonstration for heart-bypass surgeries reduced spending by 10 percent. Other demonstrations "appear to have produced little or no savings for Medicare."
Critics of the report — including some demonstration participants — noted that cost reduction wasn't necessarily the principal goal; rather, the goal was to see if care delivery could be improved in the fee-for-service model.
Nonetheless, the CBO found that there were major challenges in "developing, implementing and evaluating policies that reduce Medicare expenditures while improving or maintaining quality of care." The issue brief offers five lessons learned, which could prove illustrative as payment reforms continue to roll out and be tested:
1 | Gather timely data on the use of care, especially hospital admissions
"Programs that collected timely data on when their patients' health problems developed or became exacerbated and where they were treated seemed better able to coordinate and manage their patients' care."
2 | Focus on transitions in care settings
Programs that effectively managed care transitions had fewer hospital admissions. This includes providing education and support to patients moving from a hospital to a nursing facility, or between a primary care provider and specialists.
3 | Use team-based care
Demonstrations that had close coordination between care managers and physicians had fewer admissions. Having pharmacists help patients manage their medications was also a big advantage.
4 | Target interventions toward high-risk enrollees
Focusing on patients most at risk of being hospitalized reduced admissions. Programs based this on the patient's condition, prior hospitalization or predictive modeling.
5 | Limit the costs of intervention
There was "nearly a threefold difference" in fees paid to different organizations that combined telephone and in-person contact, suggesting that some organizations were able to deliver care more "efficiently than others."