July 11, 2016

Making Dollars and Sense with MediCaring

For roughly 20 years, a proposal to offer a new Medicare benefit for frail older people has gradually been building momentum. Named Medicaring, it's the brainchild of the pioneering geriatrician and palliative care physician, Dr. Joanne Lynn. Now, the Altarum Institute, where Dr. Lynn is the director of the Center for Elder Care and Advanced Illness, has launched "MediCaring Communities." Lynn and colleagues describe this new, revised model and offer a simulation to show how it could play out in practice in an article in the Milbank Quarterly. The bottom line is that the concept not only makes sense, but it also makes dollars and cents.

The basic premise is that we still do a poor job of caring for frail elders, exactly what I repeatedly argue in my blog posts: we prescribe the wrong medications, subject frail elders to too many tests, and provide treatment that makes sense for people with just one medical condition, not for people who are very old, have multiple chronic conditions, and suffer from impairments in their daily activities. As a result, frail elders are often hospitalized, where they develop delirium and falls and endure incontinence and iatrogenesis. If this state of affairs wasn’t bad enough, all this costs a fortune.

In response, the proponents of MediCaring Communities argue that we should instead address frailty by providing “reliable, supportive services and a care plan that reflects the frail person’s situation and priorities.” This is best achieved by integrating supportive services (transportation, social services, and housing) and medical care and by replacing some of the most expensive and burdensome medical services with additional support services. Those who would be eligible for this program would either be over 65 and have at least 2 areas of physical limitation (or dementia) or over 80, regardless of limitations. In addition to incorporating health, social, and supportive services, a community board would monitor and revise the program. And each participant in MediCaring would have a longitudinal care plan that reflects his or her personal goals of care.

The authors simulated how this program would unfold in 4 different communities, reflecting diverse environments: Akron, Ohio, Milwaukie, Oregon, Queens, New York, and Williamsburg, Virginia. Working with leaders in each area, 4 separate plans were developed that varied in the details of their operation but were similar in the overall strategy. What they found was that all 4 communities would generate substantial savings every month for each enrolled beneficiary. These savings would arise from reductions in inpatient hospitalization, decreased use of skilled nursing facilities, and lower use of long term nursing home care. In Queens, for example, the monthly savings per enrollee would total $250 in the first year, but rise to $537 by the third year. Cumulative net savings from the 4 communities was projected to be about $11 million by the end of the second year and $31 million by the end of the third year for the 15,500 eligible patients.

For MediCaring to work in practice, CMS would need to grant waivers to bypass various regulations that govern current Medicare provider organizations. But most important—and most challenging—it would require older people to be identified as frail (an estimated 10 percent of the population over age 65 is frail, with that percentage rising with age) and it would require that frail patients and their families accept the tradeoffs that underlie MediCaring. Is that a realistic possibility in this era where people don’t want to think about declining health and don’t want to limit their options?

The good news is that 42 percent of Medicare beneficiaries are enrolled in hospice at the time of their deaths--and hospice, like the proposed MediCaring program, demands tradeoffs. It's taken 30 years to reach the current level of participation: in 1987, 4 years after the hospice benefit was first introduced, only 7 percent of older patients were enrolled in hospice at the time of their death. But still today, many people only enter hospice in the very last days of life, too late to derive maximal benefit. Nonetheless, Americans gradually came to understand that their needs changed as they entered life's last phase and that hospice provides more of what they need and less of what they don't than conventional Medicare. We need to help older people and their families reach the same conclusions about MediCaring.

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