Mr. S, a 58-year-old patient, arrived in his physician’s office. He had a history of stroke that limited his ability to communicate, a seizure disorder, and has been coping with a weak dilated heart and atrial fibrillation. He lives independently and his heart rate had been well-controlled for years with atenolol. On this visit he was experiencing rapid atrial fibrillation. With difficulty because of the communications barrier, the clinical team determined that Mr. S had stopped all of his medications, including his anti-seizure drugs and atenolol, several days earlier.

Fortunately, his physician had access to a case manager who could focus on sorting out the problem. It turned out that Mr. S’s eligibility for supplemental Medicaid benefits had lapsed and his prescriptions had been denied. Because of his speech challenges, he couldn’t effectively alert anyone to his situation. The case manager was able to re-enroll him in Medicaid within 24 hours, and get him bridge doses of his medicines from the pharmacy. His heart rate was subsequently controlled, and he did not develop new seizures. An emergency room visit and, probably, a hospitalization were avoided.

Mrs. J, a depressed, 92-year-old patient who lives alone with no family in the region had chronic numbness in both legs and faced a different set of challenges. Her doctor figured out that a B12 deficiency was likely the cause of her symptoms and initiated appropriate treatment. Unfortunately, even thought the treatment was known to take weeks to months to improve the symptoms, Mrs. J began calling the office with increased frequency, with nonspecific complaints, and twice went to the hospital emergency room about her leg numbness after she had been started on the right medications to address the issue.

The case manager noticed Mrs. J’s social isolation, arranged for a social work evaluation, and linked her to a community adult day program to connect her with other seniors and reduce her isolation. She has had no further visits to the ED and overall has had fewer somatic complaints. She gets regular follow-up calls from the care team and her symptoms of depression have eased.

Mr. S and Mrs. J’s cases are typical of the complex interplay between medical and psycho-social issues that many patients coping with multiple chronic conditions have to face. Unfortunately, physician offices usually don’t have the resources to play quarterback for complex patients and anticipate or resolve these sorts of issues before they result in a costly hospital stay – one of the reasons why care for chronically ill, elderly patients has become so expensive.

Mrs. J and Mr. S are just two of 2,500 patients enrolled in a 3-year care management demonstration project at MGH funded by Medicare. The project’s mission is to find out whether more intensive management leads to better care for the sickest 5 percent of Medicare beneficiaries who account for half of the government’s health care spending. By all accounts our approach, using case management and careful tracking of the most complex patients, is succeeding in its goals: reducing costs while improving patient outcomes.

Historically, ambulatory care management has been conducted via insurance companies and been mostly ineffective. This structure was logical since insurers are the stewards of the resources needed but there’s a reason it hasn’t worked well – the principal function of insurance companies is to collect premiums and pay bills, not to manage clinical care. Care management provided by the doctor’s office is more attractive to patients because they realize that the benefits will be added to and organized by their own doctor. Our demonstration project enrolled more than 90 percent of the potential patients; typical medical management companies, working via insurers, enroll less than half.

There’s a dilemma, though: outside of a sanctioned demonstration project all of the costs but none of the savings from this sort of program accrue to the physician’s office where the savings were generated – not exactly a formula that works. Prospective, capitated payment can make the formula work but if physicians are going to take on all of the financial risk, why do we need insurance companies?

The Medicare demonstration project for high cost beneficiaries combines provider-based care management with a shared savings model that covers costs. If the performance of the program holds up and the results are confirmed at multiple sites, state government and private payers should take note.

David F. Torchiana, MD
Massachusetts General Physicians Organization