It has been an obvious and recognized truism for some time that much of the health care spending in the United States goes for a few individuals with serious, chronic diseases. It is estimated that in 2010, almost $635 billion was spent on the care of patients with five or more chronic conditions, which is 30% of total spending. $407 billion of this was spend by the federal government on Medicare and Medicaid patients. A report from the Urban Institute looks at this population of patients, the care management techniques that might be successful in managing their care and what savings might be achieved if those care management programs were more widely adopted. (Urban Institute Report)
This population of expensive patients has several sub-groups, including 9 million Medicare/Medicaid dual eligibles; the non-dual eligible Medicare beneficiary group with extensive chronic disease, about 2.3 million people; disabled people in Medicaid who are not dual eligibles; and the privately insured patients who fall into this category. The Medicare/Medicaid dual eligibles, because they often incur significant long-term care costs, are the most expensive per capita and overall of these subgroups, and the most difficult to manage because the two government programs are generally completely uncoordinated, although CMS currently has projects underway to try to fix this problem.
The report reviews the research on various approaches to care management, some of which have shown success and some which haven’t. They identify the features that appear to be linked with success, including a strong team-based approach that uses nurses to coordinate care, strong information management systems to provide close to real-time data, emphasis on teaching self-management; in-person interactions; targeted intervention and financial support and incentives. Programs with these features usually see savings in ER and hospital use that are more than sufficient to cover the cost of the intervention. The researchers estimate that if such a program were extended to a large majority of the high-cost patients, $330 billion could be saved over ten years, or about 1% of total spending. Not huge, but a good start.