A relatively small number of patients account for a high percent of health spending for any payer. A number of programs are aimed at improving care for this subset. The Journal of the American Geriatrics Society carries a research study on home-based primary care for Medicare beneficiaries. (Geriatrics Journal Article) The program focused on the very ill, very high cost beneficiaries. The research compared over 2100 controls with a set of about 720 patients who were cared for by a team that included a physician, nurse practitioners, nurses, and social workers. The physician’s did an initial visit and came back every 3 to 4 months; the NPs visited as frequently as several times a week, depending on patient condition; and the social workers dealt with environmental issues that might affect health. The doctor and other professionals were on call at all times and there was home monitoring equipment in use. One downside to the universality of the results are that the study was conducted in Washington, D.C. and the affected patients were over 90% African-American and 77% female. Primary outcomes were total spending, utilization by category and mortality, during a four-year period from 2004 to 2008. The mean follow-up period was about two years. Total Medicare spending was about $44,500 for the intervention patients and $51,000 for the control patients during the average follow-up time. The intervention patients had 9% lower hospital use and 10% fewer ER visits. They had slightly higher primary care visits, but 23% less use of specialists. There was, however, no significant difference in mortality. And the only significant difference in spending was in the subgroup of the most frail, ill patients. It also does not appear that the costs of the program were taken into account. It would have been good to have seen some patient satisfaction or other quality of life measures. I suspect that the program improved quality of care on a number of dimensions, notwithstanding the mortality analysis. And once again, we are reminded that intensive care management probably only has a payback on the few really sick patients.