Interventions that are targeted to specific patient populations and clinical areas typically have a greater impact on quality improvement and cost containment than broader approaches. In particular, ACOs should consider interventions that address the growing chronic disease burden. Chronic diseases are responsible for 75 percent of overall health care spending, with nine of 15 diagnoses at hospital admission directly related to chronic disease among older Americans.10 Given that every portion of the population has a growing prevalence of chronic disease, gaining control over chronic disease is one of the most essential elements of any health care delivery reform.
ACOs may consider using predictive modeling such as high utilization, complexity of conditions, or other clinical and socioeconomic characteristics to better target their interventions and improve return on investments. Continual development of analytical capabilities and better evidence on which interventions are most effective for specific populations will be important as ACOs continue to develop and implement their reforms.
Below we outline several promising examples of targeted interventions that can reduce
hospitalizations for specific populations and prevent complications associated with chronic disease. Chronic Disease Management
The underlying goal of disease management is to reduce the burden of disease and improve health outcomes by preventing complications and emphasizing better prevention and care management. These efforts are particularly beneficial for frail patients and those with multiple chronic conditions and can result in improved patient and family satisfaction with care and reduced costs. Necessary components of a successful disease management program
include the ability to identify and monitor high- risk individuals, apply evidence-based practice guidelines, coordinate care between providers, and encourage patient self-management through education and patient tools. The range of disease management services can include timely initiation of ancillary health services, patient monitoring and empowerment, and coordinating community services.
When these services are delivered in a timely manner, they can reduce preventable complications, emergency department visits, length and frequency of hospitalizations, and unnecessary gaps in care. In particular, diabetes, asthma, and congestive heart failure (CHF) are all areas that have been shown to be amenable to disease management activities. For example, the Camden Citywide Diabetes Collaborative was developed by the Camden Coalition of Healthcare Providers to address
growing overutilization of emergency room care due to conditions related to diabetes. Efforts include steps to increase the capacity of community- based primary care practices and medical day programs, support diabetes self-management, and improve care coordination. The collaborative has helped convert ten community-based primary care practices into certified Patient-Centered Medical Homes, develop electronic health records and a diabetes registry, and support provider education to standardize diabetes care.11
The use of an asthma nurse specialist has also been found to reduce total hospitalizations and readmissions for asthma. Specifically, asthma nurse specialists assisted primary care physicians in simplifying asthma care programs, completing daily “asthma care” flow sheets while the patient was in the hospital, educating patients in asthma self-management and developing personal asthma care plans, and providing outpatient follow-up. These activities resulted in a 60 percent reduction in total hospitalizations and a 54 percent reduction in readmissions for asthma, which amounted to
$6,462 in savings per patient in direct and indirect health care costs.12 Other successful asthma- focused disease management activities have included web-based coaching and home-based health action plans.13
There are also many CHF disease management programs. Most focus on patient education by nurses, advanced practitioners, or pharmacists with follow-up education over a period ranging from six months to three years. Experienced cardiovascular nurses at the Jewish Hospital at Washington
University Medical Center provided high-risk, elderly CHF patients with intensive education about CHF and supported efforts to encourage treatment compliance, including individualized dietary
assessment and instruction by a registered dietitian, discharge planning with social service personnel, medication analysis and reconciliation by a geriatric cardiologist, and intensive follow-up after discharge with the hospital’s home care services. They found this intervention lowered hospital readmission rates by approximately 22 percent for all causes within 90 days of discharge and 55 percent for readmissions related to CHF. The intervention also resulted in a 36 percent reduction in length of hospital stay, lowering cost of care by nine percent and producing a return on investment of 1.37 percent. Like
disease management programs for diabetes and asthma patients, appropriate program design and targeting can greatly influence the success of the intervention.14
It should be noted that for all these interventions, the evidence base has been mixed, in some cases producing significant cost savings, while in others resulting in no statistically significant changes. Importantly, studies have found that disease management programs that target higher- risk patients tend to result in a greater likelihood of reduced costs and utilization compared to programs that provide more modest interventions targeted to a patient base with mixed disease severity. Thus, ACOs should carefully consider which interventions have the greatest chance of success given their
unique patient population. It will also be critical for ACOs to develop multiple initiatives to better ensure the ability to find those that are successful.
Medication Management
Interventions that address non-adherence to medications and better medication management represent an additional opportunity for generating savings while improving patient care. It is estimated that patient non-adherence to medication costs the health care system up to $290 billion a year.15 Medication management can take many forms. It can involve a care team that includes the prescribing physician, pharmacist, or a staff member who keeps in contact with the patient. In one example, hypertension patients saw an increase in controlled blood pressure rates with web-based pharmacist care. The program began with a telephone visit between the pharmacist and the patient. Then an action plan was introduced and shared with the patient and prescribing physician. Secure web-based communication continued every two weeks until blood pressure was controlled.16 Newly evolving technologies can help to remind patients to take their medication, monitor patient adherence, and relay data back to the provider. These technologies in support of medication management programs can also inform physicians of the full costs of a treatment. For instance, CCNC (see text box above for more details) created a prescription advantage list, which ranked drugs based on cost to encourage the use of lower-cost medications when appropriate. CCNC reports lower drug spending and an estimated savings of $1 million per year due to the use of the prescription advantage list.17
Targeting Individuals with Multiple Chronic Conditions and Functional Limitations
As individuals with both chronic conditions and functional limitations represent 14 percent of
the population but 46 percent of health care expenditures, targeted interventions for this group represent a high-yield strategy.18 Individuals with chronic conditions and functional limitations (difficulties walking, performing activities of daily living, etc.) on average spend three times what others spend on health care. A great deal of this spending is dedicated to inpatient services and prescription drugs, demonstrating an opportunity for greater care coordination.
CMS is currently operating a demonstration for post-acute care (PAC) payment reform. The demonstration developed the interoperable,
electronically-based Continuity Assessment Record and Evaluation (CARE) tool to measure health and functional status of Medicare PAC and hospital discharges. CMS will use the data from the tool and demonstration to examine differences in costs and outcomes across PAC provider types. The results of the demonstration will also be used to reform payment for skilled nursing facilities, home health, inpatient rehabilitation facilities, and long- term care hospitals. As data collection on chronic conditions and functional limitations becomes more standardized, robust, and electronic, and as payment reform for post-acute settings improve provider ability to coordinate care, ACOs may find cost-savings by focusing on frailer individuals leaving acute or post-acute settings.19
A pilot from Boeing (the Intensive Outpatient Care Program) demonstrated that targeting patients with severe chronic conditions for a medical home intervention can yield cost-savings, improved physical and mental functioning, and reduce number of work days missed. Because the pilot simply targeted the highest-cost group for intensified coordination, it did not require long- term delivery system re-organization, large-scale health IT implementation, or years of change to see cost-savings. Similarly, Geisinger Health System implemented case management programs for their highest risk patients, drawing on nurse-case managers. Geisinger attributes some of its success
in slowing spending growth to this program. Another example of targeting high-cost individuals with multiple chronic conditions and functional limitations is the Care Level Management model (CLM). Care Level Management, a vendor of physician services, contracts with plans on a combination of per member per month and FFS. CLM patients have difficulty getting to medical offices, and CLM specializes in physician home visits and constant physician availability. With its focus on frail patients in the top percentiles of spending, CLM has found that its services can reduce admissions by 60 percent.20