When Depression-era gangster Willie Sutton was asked why he robbed banks, he replied: “Because that’s where the money is.”

Similarly, I’ve argued that if there is room for quality improvement and cost savings in healthcare reform, it will be in the care of those complexly ill older adults who are receiving some form of long-term care. We know from the evaluation of models such as Evercare, which brought nurse practitioners to people in nursing homes, that there is enormous room for improvement in their clinical care. More recently, we learned that rates of hospital readmission among those discharged to skilled nursing facilities are actually higher than the average (and high) rates of readmission.

We also know that rates of admission to hospitals among long-stay LTC residents are very high in the first place and that 30 to 40 percent of the time these admissions are for an ambulatory care sensitive condition such as pneumonia and congestive heart failure that could and should have been treated before a hospital admission was required.

This group of people is going to disproportionately include those with dementia, multiple chronic conditions, and self-care limitations. Their care will be paid for by Medicare for the acute and chronic health care services and by Medicaid for the custodial and supportive services (as well as co-pays and deductibles for the medical). That’s why they are known as the so-called “duals.” There are potential savings in their care, not just because of the Sutton principle (It’s where the money is being spent), but also because the quality of their care is so poor.

There is a disconnect between the complex care needs and the self-care limitations that define this group of people that means the health care system that works adequately for the rest of us can be a total disaster for them. They are also highly dependent on high-quality care to maintain function and even life itself. So for all the concerns about harming this vulnerable population in the rush to save money, I think there is a real possibility of a win-win—an increase in the quality of care and a reduction in its per capita costs.

Last week, there was good news on this front in the Journal of the American Medical Association from the Dartmouth research group led by Elliott Fisher. They looked at the results of the Physician Group Practice Demonstration (the precursor and inspiration for the current efforts to develop accountable care organizations) to find which patient populations actually contributed to savings. Using a sophisticated methodology that looked at rates of growth of spending among duals and non-duals in PGPD patients as well as patients attributed to control regions, they found that people who are dually eligible for Medicare and Medicaid (about 70 percent of whom are older adults) were disproportionately sources of savings for the sites.

Moreover the savings were substantial: between $1,000 and $2,500 per dually eligible person per year (which is a conservative estimate as it is from Medicare spending only) and occurred in both high-spending institutions such as the University of Michigan and low-spending organizations such as the Marshfield Clinic in Wisconsin.

Of course, there were also some important cautions uncovered by their work. First, there was a great deal of variability in the results across the participating sites. As usual, success is elusive and even very smart people could not consistently produce savings across the 10 sites. We can’t know if it might be due to something about the patient populations, intervention models, or contextual factors (or their interactions), but clearly we have a lot to learn and share about what works and what doesn’t in improving the care of this population.

Second, there was remarkably clear evidence that some of the PGPD sites achieved their “results” not by reducing hospitalizations or other real changes in care delivery but rather by changing the way they coded the illness of their patients over time. That allows them to “game” the risk adjustment system used by CMS to try to level the playing field between intervention and comparison regions in the face of possibly different levels of preexisting illness.

Clearly, just as we need to learn how to actually improve care, we also need to learn how to regulate and incentivize real improvements as opposed to gamesmanship. To make this more likely, we need improved performance and quality measures that will help us assess the work of new entities such as ACOs.

But here’s the bottom line: Health system leaders and health reformers generally need to pay attention to the clinically complex high-utilizing patient population and they should draw upon the expertise of geriatric specialists as they do so. Hartford grantees and alumni should stand ready by their phones—you are desperately needed.