Interventions to Manage Seriously Ill Patients

Because seriously ill patients account for so much health spending, a variety of programs have been tried to manage their care appropriately and reduce some of that spending.  Research published in Health Affairs describes one such study that appears to have worked well.   (HA Article)    Beneficiaries with what is considered an advanced illness represent 4% of all beneficiaries but 25% of Medicare costs.  Medicare is looking at new ways to pay for the care of these patients.  One potential model was developed at a large health system in California.  The program was largely intended to provide palliative care at home.  Patients had to have a high disease burden, but although much of their care was palliative they did not have to be at end of life and could receive curative care.  Home health nurses were trained to administer the care model.  There were three full-time medical directors for over 2000 patients.  While there are standardized care processes, each patient has an intensive, personalized care plan.  Patient goals and care preferences are well-documented.  The health system analyzed the effect of the program on end-of-life care, hospital use and spending.  A comparison group of similar Medicare patients not in the program was created.  Hospice use was 35% greater among the intervention group.  The intervention group also had 51% fewer deaths in the intensive care unit and overall hospital deaths were 32% lower.  The program cost about $400 a month per patient, and after considering this cost, spending was $4800 lower in the last month of life.  This was largely achieved by significant hospital cost savings.  The program did not appear to reduce spending enough to achieve savings in earlier months.  A separate independent evaluation found that the program had substantially fewer hospital days, overall savings, but slightly higher emergency room use.  This study validates the importance of intensive care management for seriously ill patients.