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JAMA. 2009 Feb 11;301(6):603-18. doi: 10.1001/jama.2009.126.

Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials.

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  • 1Mathematica Policy Research Inc, 600 Alexander Pk, Princeton, NJ 08550, USA.

Abstract

CONTEXT:

Medicare expenditures of patients with chronic illnesses might be reduced through improvements in care, patient adherence, and communication.

OBJECTIVE:

To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries.

DESIGN, SETTING, AND PATIENTS:

Eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 in 15 care coordination programs (each received a negotiated monthly fee per patient from Medicare) were randomly assigned to treatment or control (usual care) status. Hospitalizations, costs, and some quality-of-care outcomes were measured with claims data for 18 309 patients (n = 178 to 2657 per program) from patients' enrollment through June 2006. A patient survey 7 to 12 months after enrollment provided additional quality-of-care measures.

INTERVENTIONS:

Nurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely.

MAIN OUTCOME MEASURES:

Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators.

RESULTS:

Thirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, Mercy had 0.168 fewer hospitalizations per person per year (90% confidence interval [CI], -0.283 to -0.054; 17% less than the control group mean, P=.02) and Charlestown had 0.118 more hospitalizations per person per year (90% CI, 0.025-0.210; 19% more than the control group mean, P=.04). None of the 15 programs generated net savings. Treatment group members in 3 programs (Health Quality Partners [HQP], Georgetown, Mercy) had monthly Medicare expenditures less than the control group by 9% to 14% (-$84; 90% CI, -$171 to $4; P=.12; -$358; 90% CI, -$934 to $218; P=.31; and -$112; 90% CI, -$231 to $8; P=.12; respectively). Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined.

CONCLUSIONS:

Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT00627029.

Comment in

PMID:
19211468
[PubMed - indexed for MEDLINE]
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