Care Models for Complex Patients Face Barriers to Wider Adoption

Complex needs patients, those who typically suffer from numerous chronic health issues and other functional limitations, are either current or future drivers of high healthcare spending. While care models are designed to improve outcomes and reduce costs for these patients, there is only modest evidence of impact and there are a number of barriers to wider adoption of these care models in practice, according to a report from The Commonwealth Fund.

An analysis by Lyle Nelson for the Congressional Budget Office of care management program design in Medicare demonstrations found the most benefit in the interactions between care managers, patients and physicians, according to The Commonwealth Fund. Constant and close communication and interaction leads to higher success in reducing hospital use for patients and results in lower costs.

Randall Brown and his colleagues at Mathematica Policy Research, found that 4 out of the 6 Medicare demonstrations previously examined by Nelson had greater success in reducing hospital use because of the constant contact and conversations between patients and their healthcare providers. Even simple interactions, such as meeting patients in the hospital or going with them to their doctors’ appointments, showed improvement.

An experiment at Washington University, was able to achieve net savings when researchers pre-placed care managers within the practice, which had access to patient information. If the patients were admitted to a hospital, the care teams were able to receive real-time information, so that they could step in as quickly as possible.

“It’s really important to look for efficiencies and achieve the same goal,” said Douglas McCarthy, senior research director for The Commonwealth Fund and lead author of the study. “In their particular case they used what they called nurse care manager assistants, who assisted the nurse. Both care manager assistants were able to do a lot of the tasks under supervision for the lower risk patients and then that freed up the nurse to work with the higher-risk patients. That was a more efficient use of the resources to accomplish the objectives of the programs.”

When the 4 programs were examined as a group it was found that they reduced Medicare spending by 5.7% for high-risk patients. However, they were considered cost-neutral after accounting for administrative fees.

In order to keep intervention costs low and maximize savings, it is important to only target those patients who would be most likely to comply and benefit from care as opposed to targeting all patients, The Commonwealth Fund reported.

“In many cases it’s a matter of good clinical judgement and judgement by case managers, about which patients not only have the highest needs but are the most minimal to change,” said McCarthy.

Although some programs might have similarities, they can differ in results because of how they were executed as well as the different patient needs. Some programs may need to be personalized for the needs and patients of different populations.

Hospital-to-home transition was the most successful for complex patients. Studies showed that quality of care improved in most studies and the hospital use and/or costs were reduced. This constant care and personal attention to patients is extremely important for success.

The need to continuously monitor and assess patients can help determine what needs to be changed and help improve a program’s success. The Commonwealth Fund notes that there needs to be a smooth transition between programs to ensure there is no interruption of care.

Although there is some impact with the care models, they have not been widely practiced because of challenges. The barriers to success were broken into 5 parts: financial incentives; capacity to change; culture and workforce; infrastructure; and evidence.

With the intense pressure providers are under because of declining reimbursement, it may prove difficult for them to take on more work regarding patient care without appropriate compensation.