CMS: Care management pilot off to good start

Washington -- Medicare's care management demonstration project recently reached a milestone when enrollment of chronically ill beneficiaries passed the 100,000 patient mark.

The federal government says the program lightens doctors' loads, but some physicians remain skeptical that the outside intervention will be helpful.

The Centers for Medicare & Medicaid Services announced the new enrollment numbers for the Medicare Health Support demonstration project last month.

The three-year pilot, which started a staggered rollout in eight areas of the country last August, seeks to use third-party disease management firms to help maintain and improve chronically ill seniors' health.

Although the firms have been operating in Medicare for only a few months, physicians and patients are already responding well to the project, said Herb Kuhn, director of the CMS Center for Medicare Management. He said an agency report on the demonstration in early 2007 would help determine how well the plan is working.

"On the ground, the reports that we're getting are that physicians seem to be very pleased with this," he said.

"They now have another partner in the care team that is not there to get between the physician and the patient, but rather to support the patient -- to make sure that when physicians give patients their care instructions, someone is there to help them with their education, to help them with their self-care burdens and to make sure that they follow up on those instructions," Kuhn said.

The initiative's intent is to try novel ways to encourage seniors to take care of their conditions between office visits, with the desired result of reducing unnecessary hospitalizations and emergency department trips.

By using a trained nurse or health coach to call diabetic patients and remind them to check their weights and blood sugar levels, for instance, care management companies could take some of the strain off busy doctors.

The physician's role

The project's success depends in large part on how well doctors respond, said Sandeep Wadhwa, MD, vice president of care management for McKesson Health Solutions, one of the eight firms contracting with Medicare to provide the services.

Although chronically ill beneficiaries are the ones whom the government approaches to participate, disease management firms don't expect to make much headway unless physicians welcome their input.

McKesson, which is providing disease management for beneficiaries in Mississippi, attempted to avoid problems by involving physicians in its operations from the beginning.

Working with the Mississippi State Medical Assn. and others, the firm sent representatives into physician practices to develop personalized operations models that aim to integrate seamlessly with the day-to-day workings of the practices, Dr. Wadhwa said. "We recognized in our prior, more traditional disease management experiences that there was a wall in terms of the improvements we were seeing. The model of siloed nurses in a call center has some value, but it also has limits. We realized that for an elderly, frail population, a more community-based, physician-directed program would have more of an impact."

After acknowledging that a doctor would need to do some extra work to help give chronic care managers the necessary feedback on the coordination assistance they were providing, McKesson introduced a pay-for-participation element to its project.

Physicians who have patients enrolled in the demonstration and who submit information back to the managers on how well the patient education is working will receive additional compensation directly from the firm for their efforts. Already, Dr. Wadhwa said, the physician community is responding well to the incentives.

Suspicious minds

Not all physicians, however, are glad to see care management companies come into their lives through Medicare.

Some view chronic care management as something that they can -- and should -- do better on their own than with the help of an outside firm, said Vincent Bufalino, MD, a cardiologist in Naperville, Ill.

"Some physicians are wondering if this is just going to be a nurse calling them and sending the daily weights on a patient and saying that the patient is going to call the office because their weight went up three pounds this week," he said. "And on a jaded, cynical level, they're thinking, 'Did I need you to do that?' "

Dr. Bufalino, who is advising Aetna Health Management on ways to improve its Medicare Health Support operation in Illinois, said the roughly 50 physicians and 50 nurses in his cardiology practice are diligent about getting on the phone with patients on a regular basis to ensure that their heart functions remain normal. While some doctors might find it useful to have a third party do this, others will see it as redundant, a nuisance and a waste of money, he said.

Physician wariness increases when Medicare funding for these activities comes into play. While part of the disease management contractors' reimbursement depends on whether quality of care improves, the majority of the paycheck is linked to how much money care coordination can save Medicare through reduced utilization of costly services.

Physicians will be suspicious of care managers' intentions if they believe their primary purpose is to rein in access to necessary medical interventions, Dr. Bufalino said.

The AMA has said disease management can be a helpful tool, but it rejects programs whose main purpose is to constrict utilization or circumvent physicians' medical judgment.

But if doctors embrace firms that are sensitive to physician concerns and are truly set on improving health care quality, disease management as it is currently known someday might become something that is a homegrown part of most physician practices, Dr. Wadhwa said.

"The eventual home for these kinds of patient interventions is in the office, and this is likely a transition until we really demonstrate the value of these programs," he said.