As always, I read the new article by Atul Gawande in the New Yorker, The Hot Spotters, with great anticipation and high expectations. His topic was a perennial in geriatric care — targeting — the idea of finding those particular people who need and can benefit from an intervention and ensuring that they get it. Moreover, the main targeting strategy he talked about was finding those people with very high rates of utilization and expense and trying to figure out what they really need to stay healthy, stay out of trouble, and stay out of expensive hospitals. Good stuff. (Click here to see a prior post about Dr. Gawande and some video of him speaking.)
I was even more interested when in the first example he used, mapping patterns of health care use in Camden, NJ, he observed that the two "most expensive city blocks were in North Camden, one that had a large nursing home called Abigail House and one that had a low-income housing tower. . ." and that "a single building in central Camden sent more people to the hospital with serious falls—fifty-seven elderly in two years—than any other in the city. . ." This was going to be really good.
As usual Dr. Gawande captured the issues deftly, "our health-care system. . . was never designed for the kind of patients who incur the highest costs. [It] is vastly inadequate for people with complex problems: the forty-year-old with drug and alcohol addiction; the eighty-four-year-old with advanced Alzheimer's disease and a pneumonia; the sixty-year-old with heart failure, obesity, gout, a bad memory for his eleven medications, and half a dozen specialists recommending different tests and procedures. It's like arriving at a major construction project with nothing but a screwdriver and a crane." (I think the screwdriver is the brief office visit — good for tightening a few screws, but not much else — and the crane is the hospital — powerful, but a bit much, if what you really need is a ladder.)
He then describes several innovative approaches to care management and enhanced, team-based primary care that have a wider range of tools (mostly the low tech, high touch tools familiar in geriatrics) to meet these complex needs and serve people where they are in their lives.
But none of the innovative examples are with older adults, those who have the highest likelihood of having the complex situations he describes. None of the interventions in Camden or Atlantic City (where he finds new case examples) are for Medicare beneficiaries — we never get back to the nursing home or find out about all those elderly fallers. What has gone wrong?
The only innovation that Dr. Gawande mentions specifically in the Medicare program is one back at his home in Boston, at the Mass General Hospital under the direction of Dr. Tim Ferris. It is briefly described as using a nurse care manager to provide longer visits, phone calls, communication, coordination, etc. — the usual. It is described as reducing ER use and achieving a 5% cost reduction target.
But what is this demonstration? Why haven't I heard of it? I am not only a taxpaying citizen of the United States but also have been professionally following geriatric care management demonstrations for more than 10 years. What is going on?
I start Googling.
At first I think that this must be part of the Medicare Modernization Act of 2003's section 649 demonstration eventually known as the Medicare Care Management Performance Demonstration. I see that it includes Massachusetts as one of its sites. (I used to laugh about this demo, because then-Senator Blanche Lincoln of Arkansas built in a requirement to the law that her home state had to be a participant.)
I get very excited because I assume that there must be some published results for the project. But no, there are no results on the CMS webpage for the project, just lots of design papers and measurement handbooks. I take a wild guess that maybe Mathematica Policy Research might be handling the evaluation and through its website find a first year, qualitative and not very encouraging report on the initiative published in 2009 (but nothing since then).
But it doesn't matter anyway, because the project led by Dr. Ferris isn't that Medicare demonstration. His project is the Care Management for High-Cost Beneficiaries demonstration, which doesn't seem to have had a special Congressional mandate (or number) when it was started in 2005. There are no results on the web page for this demonstration either, just thumbnail descriptions of the interventions, some of which are more marketing than material. But I do see that the demonstration has been extended for three of the sites, including MGH, for another three years.
I decide to run Dr. Ferris' name through Pub Med, assuming that he might have published on his work, but no luck, although there are some nice journalistic descriptions. Discouraged, I return to the CMS website and plug the name of the demo into its internal search engine. I get a list of 255 "Reports from Centers for Medicare & Medicaid Services sponsored research available on a broad range of health care issues." A third of the way down the list - gold!!
Here it is — a report by RTI contractors on the Mass General's project from September 2010. It supports the claim that there were significant savings from the program and some very interesting improvements in care. It also describes the process of refining the model: changing the clinical team (e.g., adding more mental health expertise — even a lawyer for guardianship and competency issues), revising the IT systems; and firing the outsourced telephonic care management firm and bringing more functions in-house.
So now I know one reason why Dr. Gawande might have had a hard time reporting on innovations in care of complex older adults. Not only are we doing too few in Medicare as compared to commercially insured programs and populations, but we are making it really hard to find out about those few we have. What we learn comes out late and is never connected to other relevant material. Is it any wonder that we never seem to learn anything from one demonstration to another? What lessons (To Dos AND Don't Dos) are out there that should be incorporated into Medical Home and ACO designs, among others?
I know that being more transparent and a good partner in changing health care is one of Dr. Berwick’s top priorities for the Center for Medicare and Medicaid Services. I also know that the leaders of the new Center for Medicare and Medicaid Innovation are committed to learning while more nimbly driving the process of improvement. I hope that they will do what they can to more fully share the knowledge that we as taxpayers have already purchased.
To set a standard, Google the super-secret Joint Strike Fighter. You get a well-organized library of pictures, videos, bios, stats, and a look-up table for acronyms. You can even download a screen saver.