Zigzag Care

I’ve been debating whether or not to comment on the recent article in JAMA Internal Medicine about the importance of continuity of care for patients with dementia. Continuity seems so obviously essential for patients in general and patients with Alzheimer’s disease or other forms of dementia in particular, that it scarcely seems worthwhile studying. But then I read the accompanying commentary in the journal by Eric Larson, Vice President of Research at Group Health, who said the article addressed “what I believe may be the most important but often neglected feature of ongoing care in patients with dementia—continuity of care.” Maybe the need for continuity was obvious to me but not to everyone, so I decided to chime in to the amen chorus.

The study authors looked retrospectively at a sample of fee for service Medicare patients from 2012 who were over age 65 and had a diagnosis of dementia. They classified them as having varying degrees of continuity of care depending on whether a large share of their doctors visits were to a small number of clinicians. Then they measured health care utilization over a one-year period. After correcting for socioeconomic conditions and comorbidities, they found that the low continuity dementia patients had more Emergency Department visits and hospital admissions than the high continuity patients. They also cost the system $24,371 per year compared to $22,004 per year, a statistically significant difference.

The truth is that we already know that coordination, integration, and continuity matter for frail older people and that what’s true for the physically frail is also true for the cognitively frail. The Guided Care program, for example, which features home geriatric assessment and ongoing care by a nurse, produces superior outcomes to conventional care in managed care settings, though not in fee-for-service Medicare. The GRACE program (Geriatric Resources for the Care and Assessment of Elders), a program intended for low income seniors, utilizes a team that provides consistent care, and saves money while improving care. And the UCLA Aging and Dementia Care Program for Comprehensive, Coordinated, Patient-Centered Care, which is specifically targeted to people with dementia, also uses consistent care with resulting improved well-being and lower costs. It operates within fee-for-service Medicare by essentially adding a layer of nurse-directed coordination and continuity to what might otherwise be a chaotic system. This program is associated with increased quality of care for patients with dementia, but health care utilization and costs have not yet been evaluated.

The real contribution of the new JAMA Internal Medicine study is not showing that continuity of care is important for patients with dementia. Its real contribution is the observation that continuity of care is difficult to achieve within fee for service Medicare. The vaunted idea of maximal freedom of choice—in this case, the freedom to go to different physicians who often work within distinct health care systems—is at odds with the approach we have come to learn makes most sense for frail, older individuals, including those with dementia. If frail patients are to have the best possible care—care that is congruent with their goals of medical care, that maximizes their quality of life and level of functioning, and that at the same time is “high value” (provides the best outcomes per dollar)—they need some kind of managed care.

We make trade-offs all the time. We make trade-offs when we pay a higher price for an energy-efficient car to save on gas in the future and when we opt for a small house in exchange for access to a better school system. We make trade-offs when we choose a cheaper, generic drug over a pricier brand-name drug even though advertisements and acquaintances insist the brand name pill is superior. We need to make similar trade-offs when deciding on medical care in old age. But to make a wise choice, we need to know that we are frail (or our caregivers need to know that we have dementia) and we need to know that managed care is better care.