At this point we know a lot about problems in the care of older people that reveal themselves in elevated costs of care. We know that the relatively few Medicare beneficiaries who have multiple chronic conditions account for a huge amount of Medicare spending. We know that older adults who are depressed have twice the spending as equivalent people who aren’t depressed. We know that even patients admitted to the hospital multiple times are often released without the education or behavior change tools that they really need to manage their conditions.
What is most troubling about these facts is not the cost, but what the cost tells us about pain, suffering and waste of resources. The patient with multiple chronic conditions is running from physician to physician, taking way too many medications without coordination, and facing a very high risk of an adverse event. The patient and the family are terribly stressed and overburdened by their need to coordinate care. The depressed patient has probably been prescribed an anti-depressant, but without systematic follow-up is still not better, leading to continued complaints, poor self-care, and increased sensitivity to pain. All of this leads to wasteful care. Each hospitalization represents an episode of pain, fear, and frustration. And each hospitalization is another predictor of reductions in function and erosion of independence.
One of the most overlooked predictors of increased costs (and therefore signs of poor care) finally got its due attention at a recent Kaiser Family Foundation (KFF) briefing session kicked off by Don Berwick, MD, the new administrator of CMS and longtime quality improvement leader. On October 13, KFF released three reports looking at the impact of residing in a long-term care facility on Medicare spending and service utilization. That's right; Medicare spending, not Medicaid. Thanks to KFF we now know that long-term care residents require almost double the per capita spending for Medicare services as compared to those who don't live in some kind of institution, be it a nursing home, assisted living facility, or other non-Medicare paid non-home, residential setting.
But of course, you say! I knew it all along. People move into long-term care because they are sick, and people who are sick need more services.
That is true--but it misses the point. How are we going to improve care quality and reduce cost, while focusing on illness prevention—Berwick’s triple aim for Medicare—in nursing homes? Think of the leading mechanisms that are supposed to bend the cost curve while improving quality: medical homes and accountable care organizations (ACOs). Have you ever heard of a medical home for nursing home residents? (Other than PACE?) Do you think that accountable care organizations are going to include residents of long-term care facilities in their target populations? I suspect not. If we look at the regulations for the Medicare Patient-Centered Medical Home demonstration before it was derailed by other events, the demonstration allowed physicians to reassign patients to the nursing home physician. So when you get really sick and need the support of a medical home the most, your medical home can tell you to get lost.
When I asked about this at the KFF meeting, KFF staff said, “Yes, exactly, that’s our point for doing this meeting.” However, some attendees could not move away from their own perspective enough to see the patient perspective. For example, a leader in the long-term care industry said "of course" long-term care facilities would be part of ACOs, as any such hospital-physician partnership would want some relatively low-cost, skilled nursing facility beds to support early discharge and rehab efforts—for which Medicare already pays. I sure hope so, but my question is entirely different: will the very sick, long-term residents in those same facilities be part of the population for whom an ACO is actually accountable?
Again, I sure hope so. I think it is a win-win: long-term care residents are sick and have very high rates of utilization (like Friday evening trips to the emergency department) with often very bad consequences. Because an ACO can share in the savings from preventing such unnecessary expenses, a deep thinking ACO might want to fund more onsite nursing or physician time that would permit more appropriate treatment in these people's homes (i.e., the nursing home). This improved service would benefit the older adults and reduce overall Medicare spending, leading to shareable savings. But I am very afraid that most system-level planners will miss this win-win in taking responsibility for high-need patients and continue the current model of cherry picking.